Human Health Risks Linked to Irrigation with Treated Wastewater in Oued Souhil, Tunisia, and Gender Roles in Agriculture

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Title:
Human Health Risks Linked to Irrigation with Treated Wastewater in Oued Souhil, Tunisia, and Gender Roles in Agriculture
Physical Description:
Project in lieu of thesis
Language:
English
Creator:
Zantout, Raina S.
Publisher:
University of Florida
Place of Publication:
Gainesville, FL
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Thesis/Dissertation Information

Degree:
Master's
Degree Grantor:
University of Florida
Committee Chair:
Ullman, Jeffrey L.
Committee Co-Chair:
Russo, Sandra L.
Committee Members:
Rheingans, Richard

Notes

Abstract:
This report presents the findings of a field practicum that analyzed local perceptions and knowledge of human health risks associated with treated wastewater reuse for irrigation in the Oued Souhil region of northeastern Tunisia. This field practicum also assessed gender roles in the household and on the farmland. The sample population includes farmers who irrigate with treated wastewater in Oued Souhil, and their families, and is representative of 5% of farmers. Most farmers in Oued Souhil have been irrigating with treated wastewater since before 1980 because rainfall is unreliable and ground water is considered contaminated. Treated wastewater presents human health risks that impact farmers, their families and consumers at varying levels. Farmers especially are at risk for contracting illnesses due to their direct wastewater contact. The World Health Organization (2006) recommends controlling the amount and intensity of human exposure to treated wastewater, which can be controlled through farmers’ employment of protective equipment while irrigating (i.e. boots, gloves and long pants).
Abstract:
There are twice as many economically active males than females working in agriculture, according to recent reports. When interpreting this statistic, however, it is important to consider high rates of both undocumented and unpaid female agricultural and household labor seen throughout the Middle East and North Africa. In Tunisia, the underrepresentation of female farmers in the formal sector limits their social inclusion in agricultural extension services, such as workshops and community discussions. Methods used to carry out a social assessment of the human health impact of treated wastewater reuse were baseline surveys, structured participant observations, and a focus group discussion. Results reveal farmers’ negative perceptions towards treated wastewater and minimal knowledge of associated human health risks. Nearly one-third of farmers surveyed do not associate any health risk with treated wastewater. Farmers who reported an associated health risk primarily mentioned skin infections. Knowledge of risk for skin infections was acquired through experience or word of mouth. Agricultural extension services advising about safe irrigation practices and treated wastewater are lacking in the region. Due to several reasons, including lack of knowledge about health risks, the majority of farmers reported not using any protective equipment while irrigating.
Abstract:
Farmers’ motivations for using protective equipment were dissected using the World Bank’s FOAM framework. While boots and gloves are readily available for purchase, glove use is rare. They are not viewed as practical because plastic gloves become too hot and cloth gloves get wet during irrigation application. Boots are viewed as practical and are sometimes worn by farmers during irrigation, but on occasion with the intent to protect feet from thorns. Hygiene practices employed during and after irrigation with treated wastewater were also analyzed. There is a strong correlation between farmers who employ post-irrigation hygiene practices and those who perceive associated human health risks, suggesting that knowledge of health risks will result in safer irrigation practices, including use of protective equipment while irrigating. The culmination of this field research was a health and hygiene education workshop held for farmers and their families in Oued Souhil. The purpose of this workshop was to share and discuss human health risks associated with treated wastewater reuse, primary methods of exposure, and recommendations for safe irrigation practices. An end-of-workshop survey suggests that all participants understood the importance of wearing protective equipment while irrigating. Further, 89% would consider using them in the future. Additional surveys conducted two and 4.5 months after this workshop suggest an increase of protective equipment use while irrigating as well as greater overall cautiousness towards treated wastewater both during and after irrigation application.
Abstract:
Analysis of local gender roles revealed higher rates of undocumented and unpaid agricultural and household labor among women than men. Daily regional time poverty for women ranged from 30 minutes to five hours and consisted mainly of collecting drinking water and doing laundry. Many women and men lacked access to motorized means of transportation, relying instead on walking and cycling. Transportation and other time constraints limit women’s access to agricultural extension and other services. By adapting extension services around these gender norms and time constraints, equal access by men and women can be supported in Oued Souhil. Finally, wastewater treatment plants serving Oued Souhil are operating well over capacity. Improving the quality of treated wastewater could benefit farmers’ health. Effective wastewater treatment coupled with agricultural extension services focusing on treated wastewater reuse may reduce human health risks. Farmers’ knowledge and employment of safe irrigation practices in Oued Souhil may also minimize health risks for them and their families.
General Note:
Sustainable Development Practice (MDP) Program final field practicum report
General Note:
The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.

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University of Florida Institutional Repository
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Copyright Raina S. Zantout. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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H uman Health Risks Linked to Irrigation with Treated Wastewater in Oued Souhil, Tunisia and Gender Roles in Agriculture Raina S. Zantout A Field Practicum Report submitted in partial fulfillment of the requirements for a Master of Sustainable Development Practice degree at the University of Florida in Gainesville, FL, USA May 2014 Supervisory Committee: Dr. Jeffrey L. Ullman, Co chair Dr. Sandra L. Russo, Co chair Dr. Richard Rheingans, Member

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Abstract This report presents the findings of a field practicum that analyzed local perceptions and knowledge of human health risks associated with treated wastewater reuse for irrigation in the Oued Souhil region of northeastern Tunisia This field practicum also assessed gender roles in the household and on the farmland. The sample population includes farmers who irrigate with treated wastewater in Oued Souhil, and their families, and is representative of 5% of farme rs Most f armers in Oued Souhil have been irrigating with treated wastewater since before 1980 because rainfall is unreliable and ground water is considered contaminated. T reated wastewater presents human health risks that impact farmers, their families and consumer s at varying levels. Farmers especially are at risk for contracting illnesses due to their direct wastewater contact. The World Health Organization (2006) recommends controlling the amount and intensity of human exposure to treated wastewater employment of protective equipment while irrigating (i.e. boots, gloves and long pants) T here are t wice as many economically active males than females working in agriculture, according to recent reports. W hen interpreting this statistic however, it is important to consider high rates of both undocumented and unpaid female agricultural and household labor seen throughout the Mid dle East and North Africa In Tunisia, t he underrepresentation of female farmers in the formal sector limits their social inclusion in agricultural extension services, such as workshops and community discussions. Methods used to carry out a social assessment of the human health impact of treated wastewater reuse were b aseline surveys, structured participant observations, and a focus group discussion Results reveal negative perceptions towards treated wastewater and minimal knowledge of ass ociated human health risks Nearly one third of farmers surveyed do not

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associate any h ealth risk with treated wastewater Farmers who reported an associated health risk primarily mentioned skin infections. K nowledge of risk for skin infections was acquire d through experience or word of mouth. Agricultural extension services advising about safe irrigation practices and treated wastewater are lacking in the region. Due to several reasons, including lack of knowledge about health risks, the majority of farmers reported not using any protective equipment while irrigating. were dissected using the World readily available for purchase glove use i s rare. They are not viewed as practical because plastic gloves become too hot and cloth gloves get wet during irrigation application Boots are viewed as practical and are sometimes worn by farmers during irriga tion but on occasion with the intent to protect feet from thorns. Hygiene practices employed during and after irrigati on with treated wastewater were also analyzed. There is a strong correlation between farmers who employ post irrigation hygiene practices and those who perceive associated human health risks, suggesting that knowledge of health risks will result in safer irrigation practices including use of protective equipment while irrigating The culmination of this field research was a health and hygiene education workshop held for farmers and their families in Oued Souhil The purpose of this workshop was t o share and discuss human health risks associated with treated wastewater reuse, primary methods of exposure, and recommendations for safe irrigation practices. A n end of workshop survey suggests that all participants understood the importance of wearing protective equipment while irrigating Further, 89% would consider using them in the future Additional sur veys conducted two and 4.5 months after this workshop suggest an increase of protective equipment use while

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irrigating a s well as greater overall cautiousness towards treated wastewater both during and after irrigation application Analysis of local gender roles revealed higher rates of undocumented and unpaid agricultural and household labor among women than men Daily regional time poverty for women ranged from 30 minutes to five hours and consisted mainly of collecting drinking water and doing laundry. M a ny women and men lacked access to motorized means of transportation, access to agricultural extension and other services. By adapting extension services around these gender norms and time constraints, equal access by men and women can be supported in Oued Souhil. Finally, w astewater treatment plants serving Oued Souhil are operating well over capacity. Improving the quality of treated wastewater could benefit fa Effective wastewater treatment coupled with a gricultural extension services focusing on treated wastewater reuse may reduce human health risks. afe irrigation practices in Oued Souhil may a lso minimize health risks for them a nd their families

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Acknowledgements I would like to thank all the employees of INRGREF, CRDA and GDA. Particular appreciation is given to Dr. M ohamed Ali Bena bdallah, the General Director of INRGREF, Dr. Olfa Mahjoub, my in country supervisor, and Dr. Thameur Chaibi for their help in securing transportation and other logistics and providing research assistance during this research project. I am gracious to Mr. Ammar Neffati and Mr. Sayed Selmi for their support and service as my field companions and translators. Special thanks to Rokaya Chibani for her help conducting the focus group discussion and workshop. I give many thanks to Dr. Haithem Bahri and Mr. Ayoub Hmandi for their translation aide. I am thankful for Mohamed Ak ermi Hamdi, the Gene ral Director of CRDA, and Mrs. Azza Souissi for their support and assistance. I give many thanks to Mrs. Sabrine Harigua of GDA Oued Souhil and her wonderful staff for their support, assistance and guidance and to Dr. Aniss Ben Rayana, Director of Planning, Monitoring and Evaluation of Research Programs at ( IRESA ) for his support and input. I would like to thank Sioud Hassine, General Director of the Extension and A gricultural Training Agency under IRESA, for his guidance and support. I am grateful for Dr. Richard Rheingans, Dr. Sandra Russo, and Dr. Jeffrey Ullman, who provided priceless guidance and support during this field practicum. I give many thanks to the farmers in O ued Souhil, Tunisia, without whom this research would have been impossible. I give thanks to the MacArthur Foundation for the research grant which sustained this field practicum and to USDA FAS for their financial sup port I give many thanks to the University of Florida and the Master of Development Practice program for this opportunity as well as their kind support and guid ance Lastly, I am grateful for my family and friends for their endless guidance, support and en couragement.

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Table of Contents Introduction 1 Context 3 History 3 Development Context 4 Agriculture 5 Treated Wastewater Reuse 6 Human Health Risks 8 Exposure Routes 10 Protective Measures 11 Gender Roles in Agriculture 14 Objectives 16 Methods 17 Baseline Surveys 18 Structured Participant Observations 18 Focus Group Discussion 18 Sex Disaggregated Daily Routine Activity 20 Sex Disaggregated Community Resource Analysis Activity 20 Health and Hygiene Education Workshop 21 End of workshop Surveys 22 Data Analysis 23 Results and Discussion 25 Human Health Risks 25 Gender Roles in Agricultur e 34 Recommendations 37 Safe Irrigation Practices 37 Public Awareness and Extension Services 37 Additional Testing 39 Wastewater Treatment 40 Research about Animal Health Risks 40 Conclusion 41 Biblio graphy 43 Appendices 46

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List of Tables Table 1 : Activities, anticipated products, design process, and methods of analyses used 17 Table 2: List of activities for daily routine activity. 20 Table 3: List of resources for community resource analysis activity. 21 Ta ble 4 : Health and hygiene education workshop agenda. 23

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List of Figures Figure 1 : Institutional hierarchy of Tunisian organizations and groups. 1 Figure 2: Map of Tunisia 3 Figure 3: Average rainfall near Nabeul, Tunisia. 6 Figure 4: SE4 treatment plant in Nabeul, Tunisia. 7 Figure 5 : Conceptual framework of multivariate relationships affecting human health. 9 Figure 6 : Critical framework of compounding factors that influence human health risks. 15 Figure 7 : Health and hygiene education workshop in Nabeul, Tunisia. 2 2 Figure 8 : FOAM framework of the World Bank. 24 Figure 9 : Education data of surveyed population. 25 Figure 1 0 : Perception of human health risks linked to treated wastewater reuse for irrigation. 26 Figure 11 : Assessment of protective equipment use (i.e. boots and gloves) by farmers in Oued Souhil. 28 Figure 12 : Observed changes in water quality. 29 Figure 13 : Farmers reporting a l ink between human health risks and treated wastewater reuse 31 Figure 14 : Post irrigation hygiene practices. 32 F igure 15 : Crops irrigated with treated wastewater in Oued Souhil. 33 Figure 16 : A chicken drinking treated wastewater on a farmland in Oued Souhi l. 40

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1 Introduction In Tunis, Tunisia, I worked directly with the Institut National de Recherche en Gnie Rural, Eaux et Forts (INRGREF) which is the National Research Institute in Rural Engineering, Water and Forestry I also worked closely with the Commissariat Rgional de Dveloppement Agricole (CRDA) and the Groupement de Dveloppement Agricole (GDA) both based in Nabeul. CRDA and GDA are the Regional Council for Agricultural Development and the Group for A gricultural Development respectively. Both organizations have offices around the country. T he stakeholders of this field practicum include INRGREF, CRDA GDA the U niversity of F lorida and the Oued Souhil farmers An institutional hierarchy of these and other relevant Tunisian organizations is shown in F igure 1. Figure 1 : Institutional hierarchy of Tunisian organizations and groups. INRGREF works to advance treated waste water re use for irrigation, which includes researching salinity water and soil quality, health risks, and other topics (IRESA, 2004). INRGREF interacts directly with farmers when conducting research, while CRDA and GDA

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2 have interaction s with farmers during extension and other services Dr. Mahjoub and Dr. Ullman helped coordinate and organize this field practicum. During field visit s I was accompanied by at least one INRGREF employee Among its various tasks, CRDA the workshops offered do not i nclude wastewater related issues, they do cover topics ranging from irrigation techniques to pesticide usage CRDA is responsible for managing the transfer of treated wastewater from the storage basin in Nabeul to a control basin. From there, GDA monitors the distribution of wastewater to individual farmlands. My contact at CRDA is Mrs. The GDA office in Oued Souhil, established in 1999, is the local water users GDA focuses on the e conomic aspect of waste water reuse. That is, it serves to sell treated waste water to farmers who come to the Nabeul office and pay in advance for the ir irrigation water. The GDA office is busiest as early as March and as late as November, although the typical irrigation season is April to late September. My contact at GDA is Mrs. Sabrine H a rigua, the Technical Director.

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3 Context History T he Tunisia n Republic is situated in North Africa between Alg eria and Libya (F igure 2 ) Tunisia has a population of about 10.5 million people, with 2.16 million people working in agriculture (FAO, 2012 ). The majority of the population is between 15 and 64 years old, and the male to female ratio in this bracket is 0.97 (CIA, 2012). Overall, t here are 99 males for every 100 females in Tunisia (CIA, 2012). French and Arabic are the official languages A former French colony, Tunisia gained in dependence in 1956 and Habib Bourguiba took power. Despite enforcing a strict political rule to maintain peace Bourguiba sparked economic sector and brought both social and gender reform to the nation. His legacies include educational reform liberal economic policies that invited foreign investments and ( Schissel 1984 p.69). However, President Bourguiba did not w and it remained stagnant throughout the 20 th century Zine al Abidine Ben A li came to power in 1987 ( Perkins, 2004 ). B en Ali led another authoritarian regime ; however, it l acked the economic development sup ported by his predecessor ( Perkins, 2004 ). Ben A li remained in power until leaving Tunisia during the revolution that began in December 2010 The Tunisian revolution began in response to long term multivariate Figure 2 : Map of Tunisia

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4 effects resulting from the Ben Ali regime which included high u nemployment rates high food prices, a censored media and limited freedoms for personal expression ( Mullin and Patel, 2013). Tunisians protested demanding a new government that would continue t he social and economic progress Bourgu iba had spear headed Tunisia has been credited with sparking the Arab Spring a string of national ist uprisings occurring throughout the Middle East and North Africa when a local merchant, Mohamed Bouazizi, committed suicide in Sidi Bouzid by lighting himself on fire in a public arena (Day, 2011 ) T his revolution led to the installment of an interim government, elected in October 2011. P ockets of protest s nonetheless continued throughout Tunisia as tensions remained Some of these pockets disappeared as quickly as they appeared H owever, following the assassination of opposition figure Mohamed Brahmi in Tunis o n July 25, 2013, tensions mounted This murder, the second assassination in the country since February 2013 generated a series of national protes ts. protestors burned tires block ing roads and send ing a message of unhappiness to the interim government ( Amara, 2013; Aljazeera, 2013) The political future o f Tunisia continues to evolve Development Context Under Bourguiba and then Ben Ali, Tunisia saw 40 years of 4 5% annual g ross d ome stic p roduct (GDP) growth ; in 2010, this figure stood at 3.1%, and in 2011, after the revolution began at 1.8% (CIA, 2012). In 2011, G DP was over US$45 billion, and GDP per capita was agriculture, industry, and service sector s respectively (CIA, 2012). Additionally, 18.3%, 31.9%, and 49.8% of Tunisi respectively (CIA, 2012).

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5 French is the language o f the national education system; thus uneducate d Tunisians, who are on average older than 60 years old and live in rural areas, tend to speak only Arabic. T urbanization rate is 1.5%, with 67% of the population residing in urban area s (CIA, 2012). In total, 85% of Tunisians have access to improved sanitation facilities ; this coverage extends to 9 6% of urban and 64% of rural area s (CIA, 2012). Life expectancy is 75.24 years, and the average literacy rate of both males an d females is 74.3% (CIA, 2012). The 2012 post revolution u nemployment rate was 19% although some sources list this figure as high as 30% (CIA, 2012). Major economic industries include agriculture, mining, (EU) and include textiles, petroleum, phosphates, and food products (CIA, 2012). Similarly, mos hydrocarb ons, chemicals, and foodstuffs. Agriculture Tunisia ha s a uniquely diverse climate that varies from humid to arid in the tropical north and is characterized by desert conditions in the south. Permanent c rops cover about 15% of the country while meadows and pastures make up roughly 31% (FAO, 2012). Eighteen percent of Tunisian land remains arable (FAO, 2012). Forest area makes up around 7%, a very small percentag e co mpared to the amount of land the remaining 29% that spans the Sahara Desert (FAO, 2012). About 20% of the population works in agriculture (FAO, 2012). Tunisia major crops in order of greatest quantity p roduc ed are wheat, tomatoes and olives (FAO, 201 2 ). This field practicum focused on the Oued Souhil region found in and around the town of Nabeul in Northeast Tunisia on Cap Bon nearly 60 kilometers southeast from Tunis In this region, citrus,

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6 mulberries tobacco, corn, cactus pears, potato es, olives, grapes, and wheat are among the main crops produced. The main crops grown by farmers who irrigate with treated waste water in Oued Souhil are citrus, olives, and orange flowers which are distill ed and used for perfumes Oranges from these trees are generally not consumed raw; they are used instead to make jams Treated Wastewater Reuse Tunisi a sees little average rainfall (Figure 3) Due to climate change, a large population, and a uniquely diverse climate, there is a growing demand for water in the country (Harris, 2004). According to the Organization for Economic Cooperation and Development (2012) 95% has been exploited H igh salinity, contamination and sedimentation in local water supplies has contributed to water degradation, which has affected agricultural production (Croitoru, 2010). Treated wastewater reuse for irrigation helps reduce pressure for clean water as it offers farmers a viable alternative to rain or groundwater ( Al Salem, 2006; Frija, 2009). The presence o f plant nutrients in wastewater benefits crops, allowing farmers to reduce fertilizer use (Ensink & van der Hoek 2007 a ; Bouri, 2008 ) With wastewater reuse gaining popularity, an extensive study of human health risks and the effectiveness of ass ociated precautions should be conducte d. Figure 3: Average rainfall near Nabeul, Tunisia.

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7 A survey conducted in Oued Souhil from 201 2 1 3 revealed that n early all farmers reported irrigating with treated waste water since before 1980 ( INRGREF, 2014 ). The majority of respondents (88.9%) answered that the availability of waste water was the primary reason they began using it, with fertilization benefits (20.8%) being a second ary motivation ( INRGREF, 2014 ). In addition, nearly of those surveyed reported that the treated wastewater was not clean enough for irrigation purposes M ost farmers mentioned that they had a well on the ir farmland but its water quality was unacceptable Figure 4 : The SE4 treatment plant in Nabeul, Tunisia operat es over capacity which can lead to incomplete wastewater treatment. Here, high water levels result in inadequate clarification of wastewater. The amount of wastewater ready for treatment surpasses the processing and storage capacities of the two w astewater treatment plants in nearby Nabeul, designated the SE3 and SE4 plants. The SE3 plant serves the tourist area of Nabeul, therefore it sees more water flow during the spring and summer months, corresponding with the high tourist season. Visits to th e SE3 and SE4 plants revealed that they were working over their processing capacity, thus, the wastewater receives incomplete treatment ( Figure 4). Multiple methods of water processing and purifying

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8 during wastewater treatment has been shown to greatly red uce the amount of viruses found in the final product ( Okoh, 2010). Wastewater in Oued Souhil should be treated properly to help minimize health risks for farmers and their families. Human Health Risks P roper wastewater treatment can help ensure good enviro nmental and human health Treated w astewater destined for agricultural use must be checked regularly to assess for the presence of pathogenic enteric and other bacteria which negatively impact human health (Salem, 2011). The most prevalent organisms found in wastewater are different types of bacteria, helminthes, protozoa, and viruses (WHO et al 2006). These bacteria manifest themselves in humans mostly as skin and intestinal problems, causing itchy or red skin, diarrhea, cramping, nausea, and heada ches, among other symptoms (Salem, 2011). Farmers are at risk for parasitic infections, such as hookworm and schistosomiasis while the greatest overall human health risk associated wi th wastewater reuse is intestinal helminth infection, especially for chi ldren (Siebe, 1995; WHO et al 2006). H elminth eggs present an enormous risk because they can stay alive in the irrigated soil for several years (WHO et al 2006). Children of farmers are also at risk for contracting diarrheal disease and sa lmonella (WHO et al 2006). Tests conducted on treated wastewater in various parts of Tunisia revealed notable amounts of Escherichia coli and Salmonella bacteria (Salem, 2011). These bacteria are known to cause painful intestinal infections that can result in severe intestinal issues. Farmers in Nairobi, Kenya, who i rrigate with treated wast ewater reported having diarrhea stomach aches, intestinal worms, and skin infections (Ndunda, 2013). A study in Vietnam revealed a direct relationship between fa rmers who come into direct contact with wastewater and those who reported skin problems (Trang et al., 2007). The two main types of skin problems found, according to

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9 dermatologists were dermatitis (eczema) and fungal skin infections (Trang et al., 2007). T hese skin problems were found primarily on legs and feet, suggesting a direct relat ionship between these health issues and direct wastewater contact during farming activities I t is c portant risk factor for skin ( 2007) also suggests a direct relationship between direct wastewater contact and skin problems Although no related studies were found in the context of treated wastewater reuse for irrigation in Tunisia, these reports sugges t that human health risk s may also exist in Oued Souhil. Figure 5 illustrates how various elements overlap to affect human he alth. The degree of wastewater treatment impacts both crop safety and recommended i rrigation techniques. T hese and other elements such as the presence of agricultural extension services, af fect human health Regional gender norms also influence agricultural roles resulting in d ifferent exposure levels to treated wastewater The se roles will be further discussed in the section Gender Roles in Agriculture Figure 5 : Conceptual framework of multivariate relationships affecting human health.

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10 Exposure Routes H umans can acquire infection through both direct and indirect wastewater contact as well as by ingesting contaminated crops and water (Salem, 2011). These methods of transmission are described here 1. Direct contact with treated wastewater Most health issues associated with treated wastewater are experienced by farmers and result from direct wastewater contact Direct contact can occur through the emersion of exposed hands, feet and legs as well as by water splatter on vulnerable areas such as hands and the face. Farmers have the highest risk of contracting bacteria from wastewater if they employ furro w or flood irrigation, which entails water flowing on the soil surface (WHO et al, 2006). Most farmers surveyed in O ued Souhil reported using this type of irrigation ( INRGREF 2014 ). Additionally, contaminants found on handles of agricultural tools can come exposed hands. 2. Indirect contact with treated wastewater and especially children, are at risk for indirect wastewater contact caused by exposure to dirty agricultural clothing, boots and tools, wh ich may be brought into or stored near the home 3. Ingestion of treated wastewater I ngestion can occur during irrigation i f the treated wastewater splatters and lands on face or hands. 4. Ingestion of contaminated crops Consumers of crops irrigated with treated wastewater have reported helminth infections, cholera, typhoid, sh igellosis, and diarrhea in various parts of the world (WHO

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11 et al 2006). Pregnant women and children are especially vulnerable to these hazards (Al Salem, 2006). Crops may become contaminated af ter heavy rainfall when soil splashes onto low growing fruits and vegetables Crops may also become contaminated during spray or sprinkler irrigation because the y come into direct wastewater contact ( WHO et al 2006). T his type of irrigation was not ob served in Oued Souhil 5. Ingestion of contaminated surface and groundwater Most f armers in Oued Souhil revealed during this study that they perceive their groundwater to be contaminated with bacteria or salt T herefore, it is not consumed, although s ome farmers reported mix ing well water with wastewater for irrigation purposes ( INRGREF, 2014 ) Using contaminated g ro undwater for irr igation suggests similar human health risks as using treated wastewater, if this water source is actually polluted. Ingestion may occur during irrigation in the contaminated water splatters and ce or hands. Protective Measures Protection for Farmers Among other measures to limit the burden of disease associated with treated wastewater reuse, the World Health Organization (2006) suggests controlling the amount and intensity of human exposure Protective equipment, namely gloves, long pants, and boots that are tall enough, should be worn by farmers during irrigation to prevent direct wastewater contact. A 2011 study conducted in Nairobi revealed that about 78% of farmers agree that protective c lothing, such as boots and gloves, can minimize their exposure t o harmful pathogens found in treated wastewater (Ndunda, 2013). Other methods of reducing associated human health risks agreed on by these farmers include: minimizing soil splash on vegetables grown (72% agree);

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12 effectively treating the wastewater to remove path ogens (63% agree); applying treated wastewater on the roots of crops, not on their leaves (57% agree); and ceasing irrigation a few days before crop harvest ing (44% agree) (Ndunda, 2013) This 2011 study suggests that farmers who irrigate with treated wastewater possess an understanding of the associated human health risks and safe irrigation practices, even if they do not employ them. D irect wastewater contact can be avoided by employing protective equipment during irrigation F armers should also be mindful of wastewater splatter and other forms of cross contamination that may occur during and after irrigation irrigation practices ma y also minimize associated health risks for their families. Proper Wastewater Treatment Treated wastewater destined for agricultural use must be regularly monitored for pathogens (Salem, 2011 ). I mproperly treated wastewater can pollute soil s and surface an d groundwater (Al Salem, 2006). According to Al Salem (2006), there are six processes for wastewater treatment that can result in the complete removal o f helminth eggs and other pathogens: 1) waste stabilization ponds, allowing 2 3 weeks for bacteria remov al; 2) effluent storage that may reduce treatment time; 3) secondary treatment chambers; 4) secondary chambers followed by sand filtration; 5) chemically enhanced primary treatment; and 6) secondary chambers with filtration using membranes. Proper wastewat er treatment requires appropriate operation and management, and effluent quality can be enhanced by new technologies if needed Abiding to international and national guidelines and policies can help promote the safe processing and subsequent reuse of treated wastewater (Al Salem, 2006).

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13 Crop Safety While wastewater splatter may contaminate crops, other e nvironmental factors also impact the presence of harmful organisms on crops including humidity, tempera ture, soil content, direct sunlight, and plant type (WHO et al 2006). H armful organisms can survive on crops after harvesting and even during refrigerated storage, presenting a health risk for food handlers and consumers A simple yet effective solution is to thoroughly wash or cook these crops prior to consumption which can remove or kill nearly all infectious organisms (Ensink et al. 2007 b ). Cooking eliminates more bacteria than does washing crops ( WHO et al 2006). There does not appear to be a substantial difference in the amount of pathogen removal when vegetables are washed with water alone, water and a disinfectant, or water and a detergent ( WHO et al 2006). The most common en teric viral infections found in hu mans who consume contaminated raw vegetables are acute gastroenteritis and hepatitis A (Ok oh, 2010). Intestinal nematodes due to the ingestion of helminth eggs are also of concern (Al Salem, 2006). The type of crop produced with treated wastewater should be con sidered when assessing for human health risks Root crops, like p otatoes come into direct contact with waste water infiltrating through the soil, present ing a greater human health risk than tree crops, including mulberrie s and olives For this reason the irrigation of potatoes and other root vegetables with treated wastewater in Oued Souhil is prohibited Additionally, the World Health Organization (2006) recommends ceasing irrigation with treated wastewater at least two weeks before crop harvesting It is unclear whether this practice is customary in Oued Souhil. In addition unhygienic or careless food handling may result in the pos t harvest contamination of crops (Okoh, 2010). In Oued Souhil, citrus and olive tree s dominate the landscape. C itrus fruits are peeled, thereby removing nearly all pathogens prior to consumption ;

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14 they present a low avenue for infection ( WHO et al 2006) O lives present a higher risk for post harvest con tamination because they lack a natural protective casing Many farm ers in the region reported soak ing their olives in olive oil and/or lemon juice for several weeks or months after harvesting. A wareness and employment of sanitary crop harvesting and processing methods may minimize the post harvest contamination of crops d esignated for human consumption, thereby reducing associated human health risks Gender Roles in Agriculture T here are twice as many economically active males than females in the agricultural sector in Tunisia (FAO, 2012). However, many Tunisian women who labor on the land are not viewed as active participants in agricultural production (Harris, 2004). Due to this discrepancy in documenting female agricultural workers, women tend to receive less direct benefits from organizations working in the region. This situation warrants female specif ic initiatives that work to clos e this gender gap Th e planning of these initiatives requires di saggregated agricultural baseline data which should examine aspects such as gender based land rights employment, cultural roles, and socia l constraints The history of rural female farmers in Tunisia shows that their duties and responsibilities have become greater during the past century due to increasing male labor migration to urban areas (Latreille, 2008). With men absent, women were left to manage the farmland household and children. This shift in responsibility has had several significant effects, especially within the context of the male dominated Arab culture found in Tunisia and throughout the M iddle East and North Africa Most notably, women in Tunisia found themselves carrying out tasks that were traditionally assigned to men thus leading to women acquiring greater decision making power over time (Latreille, 2008). More women now view themselv es as the head of househ old because

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15 of their increased responsibilities and decision making power (Latreille, 2008). Finally, Tunisian women achieved significant political rights under President Bourguiba, allowing them near equal status with men accordin g to the Personal Status Code of 1956 (Perkins, 2004). This historical progress is a solid foundatio n f or any female specific agricultural development initiatives A comprehensive framework ( Figure 6 ) depicts how the varying aspects of treated wastewater reuse affect human health and how gender roles come into play Gender constraints, such as time poverty and daily household duties extension services which can disseminate informa tion about safe irrigation practices including use of protective equipment while irrigating Time poverty refers to the average amount of time spent collecting resources or doing chores without modern advances in technology, such as household water taps, washing machines, and hot water heaters. Figure 6 illustra tes how a change in one aspect might affect other aspects and ultimately human health. Figure 6 : Critical framework of compounding factors that influence human health risks.

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16 Objective s The objectives of this field practicum were to: 1. Conduct a social assess ment of the human health impact of treated wastewater reuse by ; 2. D esign and implement health education workshops awareness of human health risks and safe irrigation practices ; 3. E valuate perception, knowledge and motivation after workshops to allow insight for developing additional extension services and educational tools; and 4. Conduc t an analysis of gender roles in agriculture and acquire disaggregated data to help identify regional education and extension needs The deliverables of this field practicum can be found in Appendix I.

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17 Method s M ethods consistently pursued a participatory approach and are listed in T able 1 A timeline of all activities can be found in Appendix II Ac cording to the Institutional Review Board at the University of Florida, this research project was approved for up to 300 participants between the age s of 18 and 80. Participation in activities wa s voluntary and participants had the right to withdraw at any time without penalty. All participants involved in this field practicum were randomly selected and received zero compensation There were no direct benefits or risks for p articipants who were informed of these guidelines. Table 1 : Activities, anticipated products, design process, and methods of analyses used, in chronological order. Activities are color coded to reflect collective modes of delivery. Structured participant observations were part of baseline surveys. Likewise, both sex disaggregated activities occurred during the focus group discussion, while the end of workshop surveys happened upon completion of the health and hygiene education worksh op. Activities Anticipated Products Design Process Analysis Baseline surveys Situation analysis; Gender analysis; Assessment of knowledge perceptions and behavior Questions drew from and complimented INRGREF survey Stata 13.0; FOAM Structured participant observations I dentification of key intervention points Observations of farming practices FOAM Focus group with women with any relation to the irrigated land Health analysis; Gender analysis Questions drew from survey results FOAM Sex disaggregated daily routine activity Gender analysis; Assessment of female time poverty Derived from Feldstein and Jiggins ( 1994 ) Qualitative Sex disaggregated c ommun ity resource analysis activity Gender analysis; Assessment of regional resource demand an d availability Derived from Feldstein and Poats (1989) and Feldstein and Jiggins ( 1994 ) Qualitative Health and hygiene education workshop Identify safest irrigation practices Topics pulled from all results Qualitative End of workshop s urveys Assessment of knowledge and motivation gained Questions to assess immediate response Stata 13.0

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18 Baseline Surveys S urveys were randomly conducted in Oued Souhil to acquire baseline data about irrigation practices perceptions towards treated wastewater, and knowledge of associated human health risks. The sample population was f armers who irrigate with treated wastewater in Oued Souhil and their families This survey sought to discover whether or not an association between health and irrigation existed among farmers. Q uestions drew from and complimented the 2012 1 3 INRGREF survey previously referenced Baseline surveys included demographic but not socioeconomic questions. Q uestions that provided insight into farming practices and household chore s were also addressed to help shape a theory about local gender roles Survey questions were asked in Arabic and translations were given in French. A copy of this survey can be found in A ppendix I II Structured Participant Observations Baseline surveys included structured participant observations of irrigation activities. If the farmer was approached outside of his/her irrigation practice, no observations were noted. The following aspects represent the structure of these observations : 1) water color, quali ty, and smell; 2) any measures for protection employed by the farmer and their observed level of dirtiness; 3) any apparent health risks associated with the irrigation process; and 4) any additional comments. The template used for these observations can be found in A ppendix IV Focus Group Discussion A focus group, held at the GD A office in Nabeul, Tunisia, consisted of a health discussion followed by two sex disaggregated activities. The discussion served to follow up on information acquired during baseline surveys while the activities served to obtain a gender analysis of the local agricultural sector T o encourage a more open discussion about gender roles,

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19 only women were invited to attend this focus group discussion Six women attended, o f 24 invited. All but one participant actively worked on farmland yet all were engaged in the health discussion. F ive of the six attendees had participated in the baseline surveys These figures, though small, suggest that individuals who are already familiar with the researcher will be more invested in research activities than individuals who were previously not involved. The objectives of the health discussion were to assess : 1. U nderstanding of sanitation and hygiene, especially as related to treated wastewater reuse for irrigation; 2. Knowledge of human health risks associated with treated wastewater reuse; and 3. G eneral attitude to wards treated wastewater reuse. The objectives of the activities were to : 1. A cquire gender disagg regated data; 2. G ain an understanding of local wom 3. A ssess the local gendered division of labor in the agr icultural sector. It was not apparent that any socio economic factors influenced the focus group discussion. This discussion w as conducted in Arabic recorded, and notes were taken in French by Dr. Haithem Bahri The activities were also conducted in Arabic and written in French. Dr. Olfa Mahjoub moderated this focus group Q uestions posed during the discussion can be found in App endix V After the discussion, which lasted one hour, p articipant s were paired with a volunteer to complete the activities which are further detailed below Family members completed activities together and a mother daughter pair was present T hus, of six focus group participants, there are five activity sheets.

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20 Sex D isaggregated D aily R outine A ctivity Th is activity served to acquire a gendered analysis of routine daily activities of a typical rural household in Oued Souhil. The activity sheet listed 18 agricultural and nonagricultural activities (Table 2). For each task three question were asked: who undertook the task, t he average time required to complete the task, and what time of day each task occurred ( morning, afternoon or evening ) Answers help ed frame an understanding of intra household decision making and gendered time poverty. This activity also served to uncover during which time of the day men and women are busiest. Five c olor coded stickers representing the woman, her husband, female children, male children, and an other person (s) were used to identify who undertook each task A template of this activity sheet can be found in Appendix VI. Table 2: List of activities for daily routine activity Cooking breakfast Buying water (if a tap is not in the home) Cooking lunch Making coffee/tea Cooking dinner Doing household repairs Bringing lunch to your husband on the farmland Feeding livestock Doing laundry Working on the farmland during the irrigation season Buying groceries Working on the farmland outside the irrigation season Housecleaning Taking children to school Buying clothes Picking up children from school Making clothes Bathing/ getting children ready for the day Sex Disaggregated Community R esource A nalysis A ctivity Th is activity sought to provide a gender ed analysis of certain household and agricultural tasks a nd a contextual understanding of regional resource demand availability and locatio n. This

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21 activity also gave further insight into local time poverty A list of all r esources discussed is shown in Table 3. The same five c olor coded stickers were employ ed to carry out this activity This activity revealed where certain resources were located in the community, who was in charge of collecting that resource, who paid for it how they traveled to access the resource, and who made most decisions regarding it s usage A template of this act ivity sheet can be found in Ap pendix V II Table 3: List of resources for community resource analysis activity. Potable water Supermarket/Grocery store Treated wastewater for irrigation Doctors Farmland Money Agricultural tools Farmland employees Protective equipment (for use during irrigation) Community extension services and meetings Fertilizer/Manure Information exchange with neighbors Livestock Harvesting crops Feed for livestock Laundry Livestock products and byproducts Health and Hygiene Education Workshop A two hour workshop w as conducted at the GDA office in Nabeul with an open invitation for all farmers who irrigate with tre ated wastewater in Oued Souhil and their families (Figure 7 ) The purpose of this workshop was to share and discuss the hum an health risks associated with treated wastewater reuse primary me thods of exposure to risks, and recommendations for safe irrigation practice s I t sought to assess perceptions and knowledge of wastewater reuse a nd associated health risks, and encourage use of protective equipment during irrigation t o promote farmers The information presented (Table 4 ) drew from extensive research as well as results from baseline surveys, structured participant observations, and the

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22 focus group discus sion. Of the target population, 29 farmers and their families were randomly selected and invited to participate i nclud ing all focus group and baseline survey participants. Ten farmers atten ded this workshop (six women and four men) End of workshop Surveys A t the end of the health and hygiene education workshop, a brief survey was conducted to gauge methods of exposure. It also uncovered post workshop perceptions towards treated wastewater reuse and proposed precautionary measures, particularly use of protective equi pment (primary measure). One farmer arrived one hour late to the workshop and was excluded from this survey, as he had missed half of the discussion. Family members were surveyed together, and again there was a mother daughter pair. Therefore, there are se ven end of workshop surveys reflecting information from ten participants. A copy of this survey can be found in Appendix VIII. All surveys were given orally in Arabic with translations written in French Figure 7 : Health and hygiene education workshop in Nabeul, Tunisia.

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23 Table 4 : Health and hygiene education workshop agen da. Data Analysis Baseline surveys and end of workshop surveys were processed and analyzed quantitatively using Stata 13. 0 software The success of the health and hygiene education workshop was determined using aforementioned end of workshop surveys as well as additional surveys conducted two and 4.5 months after the workshop by INRGREF Data derived from the two activities completed during the focus group discussion were disaggregated and interrogated

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24 The health discussion and structured participant observations represent q ualitative data collection and were processed using the FOAM (Focus, Opportunity, Ability, and Motivation) framework (F igure 8 ) This framework was developed by the Water and Sanitation Program of the World Bank to disse ct and analyze hand washing attitudes and behaviors (Coombes and Devine, 2010). It was adapted for this study to allow for an analysis of health knowledge, attitudes, beliefs, and behaviors as they relate to treated wastewater reuse for irrigation in Oued Souhil. Specifically, the FOAM framework used for this field practicum investigates use of protective equipment ( boots and gloves) by farmers while irrigating Within the framework, o pportunity seeks to identify whether or not an individual in the target population has the resources necessary to perform the target behavior. Ability measures motivation analyzes different factors affecting the he target behavior. Using the FOAM framework allowed for a multi faceted assessment of all factors affecting the relationship between human health and treated wastewater reuse for irrigation in Oued Souhil Figure 8 : FOAM framework of the World Bank.

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25 Results and Discussion Human H ealth Risks This study surveyed five percent of farmers who irrigate with treated wastewa ter in Oued Souhil Tunisia, and is therefore representative of 13 households. Only two farmers surveyed were not also the proprietor. This sample inc ludes eight women and five men, all of whom reported irrigating with treated wastewater since before 1980 due to its availability. Secondary reasons for using treated wastewater include its fertilization benefit s and concerns about drought. E ducation information for farmers and their fam ilies are displayed in Figure 9 Figure 9 : Education data of surveyed population.

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26 Baseline data show that about 38% of farmers believe human health risks are linked to treated wastewater reuse for irrigation (Figure 1 0 ). Sixty percent of respondents who identified this linkage to health risks stated that skin problems could result from direct wastewater conta ct. Nearly half of farmers experienced an illness which they attributed to treated wastewater, and 15% mentioned an illness in their family which they also attributed to waste water (INRGREF, 2014). Only 31% of farmers surveyed felt that their treated wastewater was sometimes or always clean enough for irrigation. Dermatose s was often mentioned when an association was drawn between treated wastewater reuse a nd human health Notably, one respondent claimed to have skin problems, and a second said that a friend had a skin infection on the feet. In addition, s tructured participant observations were recorded during about one third of baseline surveys. hands and face. Figure 1 0 : Perception of h uman h ealth r isks l inked to t reated w astewater r euse for irrigation human health risks associated with treated wastewater reuse for irrigation. No direct relationship ed educational differences among household heads. There is no significant relationship between the highest 38.40% 30.80% 30.80% Yes No Don't know

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27 treated wastewater reuse for irrigation in Oued Souhil. Ho wever, t he results of the FOAM framework (F igure 1 1 ) allow for while irrigating in Oued Souhil While boots and gloves are readily available, glove use is rare because they are not seen as prac tical. Plastic gloves become too hot and cloth gloves get wet. Remarkably, none of the farmers surveyed reported wearing gloves while irrigating. On the other hand, half of farmers reported wearing boots while irrigating. B oots are viewed as practical, but on occasion they are worn with the intent to protect feet from thorns rather than wastewater.

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28 Figure 1 1 : Assessment of protective equipment use (i.e. boots and gloves) by farmers in Oued Souhil. Focus Opportunity Ability Motivation Knowledge Farmer is lacking information or only has a basic understanding of human health risks from experience or word of mouth Belief and Attitudes Direct contact with water is unhealthy, but r isks are overlooked. Boots perceived as practical; gloves are not Water has been safe. Access/ Availability P rotective equipment is readily available Target Behavior Use of protective equipment (boots and gloves) while irrigating Social Norms Use of boots is common ; glov es are rare. Social Support Information lacking about human health risks Irrigation with treated wastewater is a common practice, so discussion of risks is welcome. Target Population Farmers who irrigate with treated wastewater in Oued Souhil, Tunisia Outcome Expectations Protective equipment can lower risk for skin infections. Product Attributes Boots and gloves protect from direct contact with wastewater. Threat Belief that showering after irrigating eliminates health risk. Intention Boots worn to protect feet from thorns.

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29 Many farmers view their treated waste water negatively comment ing that it is dirty of variable quality has problems with distribution and has a dark color. Additionally, 77% of survey respondents answered that the qual ity of their treated wastewater has changed in recent years, and 60% of them reported more than one type of change. Figure 12 depicts perceived changes in waste water quality. T he majority of instances when treated wastewater was seen on the farmland while conducting baseline surveys it was noted to be brown or light brown and had a strong, foul smell. Some farmers also commented that the quality of their treated wastewater worsens during the summertime. Figure 1 2 : Observed c hanges in w ater q uality. The health and hygiene education workshop began with a discussion of the advantages and inconveniences (disadvantages) of lo cal treated wastewater used for irrigation purposes Answers taken from prior data collection were written on a large cha rt At the beginning of the workshop, this list had nutrients and bacteria / viruses as initial advantages and disadvantages, respectively No advantages of treated wastewater were added during the workshop On the other hand, i nconveniences added by participants are : microbes; burning sensation after direct contact; 80% 70% 60% 50% 10% 0% 20% 40% 60% 80% 100% Turbidity Foam Odor Color Other Percent of farmers All Reponses* *Respondents could answer more than one measure.

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30 odor; different taste of crops; wastewater splatter on to farmers; and the restriction on growing vegetables. W hen asked during the focus group could transmit illnesses or disease, the group agreed that it could not. Although this response limited the potential of th e health discussion, participants continued to share information about their irrigation practices. As a whole, members of th e focus group did not employ boots or gloves but did take showers after finishing irrigating for the day Many farmers believe showering after finishing irrigati ng for the day eliminates health risks, thus use of boots or gloves is deemed unnecessary. Many farmers also mentioned throughout this study that because the wastewater has been treated, it presents no health risks, even if it appears brown and turbid. These impressions contribute to low overall employment of protective equipment during irrigat ion by farmers. These response s also highlight the fact that many farmers in Oued Souhil lack information about effective hygiene practices and have only a basic understanding of health risks from experience or word of mouth. When asked during the focus g roup what recommendations they would give other farmers who also irrigate with treated wastewater, some participants an swered simply that farm workers should try to avoid touching the water directly. This advice suggests an understanding among some partici pants that their current irrigation practice is risky. However, participants then commented that they are always at risk for direct wastewater contact while irrigating, so this advice would be hard to actualize. After the workshop, many p articipants menti oned they understood the importance of protecting themselves, specifically by washing their hands (before eating; after irrigating), wearing boots, gloves, and long pants, and not bringing dirty irrigation clothing into their home. In addition, all farmers mentioned understanding the importance of avoiding direct wastewater

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31 contact by wearing protective equipment while irrigating They cited newfound awareness of human health risks and on Reported c hanges in knowledge of the relationship between treated wastewater and human health risks before and after the workshop are shown in F igure 13 Follow up s urveys conducted by INRGREF two and 4.5 months after the health and hygiene education workshop reveal that all participants thought the workshop was beneficial, and that information dissemination was popular in the region All participants reported sharing information with their immediate family, while some reported also discussing the wor kshop with their neighbors. A t the end of the workshop, 89% of participants reported considering future use of protective equipment while irrigating. Two months after the workshop, 60% of participants reported a change in their irrigation practice. These r esults suggest that the health and hygien e education workshop caused increased u se of protective equipment by farmers in Oued Souhil as well as greater overall cautiousness towards treated wastewater both during and after irrigation. Figure 1 3 : Farmers reporting a link between human health risks and treated wastewater reuse 0 5 10 15 Before WS 2 months after WS 4.5 months after WS Number of respondents Timeline Yes No/Don't know

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32 Nearly 39% o f farmers surveyed r eported living on the irrigated farm land while the rest have houses on another property. L iving on farmland mak es farmers and their families more susceptible to health risks due to the increased amount of time spent in close proximity to wastewater. When asked whether or not these farmers avoided contaminating their household with bacteria from treated wastewater, 60 % answered yes. Figure 1 4 depicts the popularity of common hygiene practices to avoid household contamination with treated wastewater and is based on all survey responses Figure 1 4 : Post irrigation h ygiene p ractices There is a strong correlation between farmers who employ post irrigation hygiene practices and those who perceive associated human health risks, suggesting that knowledge of health risks will result in safer practices. Additional survey questions revealed that the majority of farmers use soap when washing their protective equipment, hands, face, feet, or legs, while some reported using nothing but water. Cross analysis of data suggests that after irrigating, 85% of farmers surveyed wash their hands or s howe r with soap 62% 54% 46% 31% 8% 0% 20% 40% 60% 80% 100% Shower Leave boots or gloves outside Leave clothes outside Wash hands, face, feet, or legs Wash boots or gloves Percent of farmers All Reponses* *Respondents could answer more than one measure.

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33 Another factor that may present human health risks is the common use of manure in Oued Souhil as a soil supplement as indicated by 92 % of farmers surveyed. Almost half of these households use manure from their livestock. However, no direct correlation was found between farmers who use m anure and those reporting skin problems, diarrhea, or stomach issues. Figure 1 5 shows the prevalence of major crops irrigated in Oued Souhil with treated wastewater among farmers who participated in the basel ine survey All farmers reported that they sold their agricultural products Regarding consumption, 90% of farmers who pro duce crops other than o range flowers which are distilled for perfumes and cannot be consumed an swered that they also ate their crop Over 75% of farmers who consume their own pr oduct claim ed that its taste had changed since using treated wastewater for irrigation purposes In addition, o ne respondent answered that the smell of the distilled orange flowers had changed. Figure 1 5 : Crops i rrigated with t reated w astewater in Oued Souhil Farmers involved in this field practicum expressed strong interest in obtai ning more information about safe i rrigation practices. They a lso requested to be informed about the extent of wastewater t reatment. Knowledge of this treatment level may correct their perceptions of safety and allow them to take proper measures for protection during and after irrigati o n. Some Citrus Olives Orange flowers Other 61.50% 38.50% 85% 23% 0% 20% 40% 60% 80% 100% Percent of farmers Major crops

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34 farmers also expressed their desire for further analyses of their soil and water sources. Participants discussed their negative perceptions of groundwater, calling it salty and polluted and reported shortages of well water. Participants also shared that it has been two years since vaccinations were ava ilable in Oued Souhil It appears some famers believe that certain vaccinations will protect them from human health risks associated with treated wastewater reuse for irrigation. Finally, animal health is another concern expressed as m any farmers have livestock or other animals that are exposed, at varying levels, to treated wastewater. These health related concerns suggest that participants are interested in protecting and improving their health, despite their risky irrigation practices. Gender Ro les in Agriculture Many farmers reported a high degree of female decision making power in the household. When both spouses are present in the household, the family budget was just as likely to be managed by the husband as by the couple together. However, s ome resources are more likely to be managed by the husband such as potable water, livestock feed, and livestock manure In addition, g oing to the GDA office in Nabeul to pay for treated wastewater was much more likely to be done by the husband. When asked who else helps to work on the farmland, including irrigating, harvesting and cleaning crops and preparing products to sell, all male respondents answered that their wives help them. Few male respondents answered that their children or an employee also hel p s For the same question, f emale respondents answered that their husband, chil dren or an employee help. G ender roles are strongly influenced by agencies and policies. An i making power stem s from the rules and actions of organizations around them. For instance, about 92% of women surveyed in Oued Souhil acquired their farmland through inheritance,

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35 strongly suggesting no agency limitations on sex and land rights (INRGREF, 2014) Second, extension services are often offered in the mornings when women are busiest thus limit ing their active inclusion W omen in Oued Souhil tend to be busiest in the mornings with tasks such as cooking, cleaning, doing laundry, and irrigating and working on the farmland. Many women are the sole undertakers of these daily chores, which often last into the afternoon. Extension services that work around gender norms can help provide equal access for men and women Heightened female social inclusion in Oued Souhil can help increase their decision ma king power. A gender based discrepancy exists that can impact regional statistics, foreign and local aid programs, and personal views of importance and worth. As discussed, u ndocumented and unpaid female agricultural and household labor are preval ent throughout the Middle East and North Africa Whi le these types of female labor are traditionally undocumented, especially in agriculture their recognition is vital for many reasons, including promoting female self worth (Latreille, 2008). The most time consuming tasks for women i n Oued Souhil lasted up to five hours and consisted of collecting drinking water doing laundry cleaning the house and irrigating the farmland Observations in and around Oued Souhil reveal that walking, cycling and riding a s cooter are the most common forms of transp ortation; having a car is rare for both men and women W ccess to and inclusion in agricultural extension services in Oued Souhil is limited by transportation, time, household duties and other constraints By adapting services around these constraints, the social inclusion of women in the agricultural sector can be improved Furthermore, u nderstanding gender roles is critical to determin e which methods of aid and development will be most successful and to w hich sex to best target these efforts. T his study suggest that many women cannot attend extension events and workshops because they have

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36 other time commitments, face cultural barriers, or lack transportation. Adjusting extension services to counter these constraints can offer women a realistic opportunity to attend engage and learn Noting culturally appropriate areas to house workshops would prove beneficial because men and women should not mix in every public space according to cultural norms Providing a car to deliver women to extension events at appropriate times of the da y will also help remove some gender based barriers. These and other efforts should work to promote the inclusion of both sexes in agricultural ext ension services in Oued Souhil.

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37 Re commendations Safe Irrigation Practices It is recommended that safe irrigation practices be employed in order to mitigate human health risks associated with treated wastewater reuse These practices include : hand washing at key points including after irrigating after treating livestock, and before consuming food or water (WHO et al 2006) ; wearing protective equipment, particularly boots gloves and long pants (Siebe, 1995 ; WHO et al 2006 ); avoiding bringing contaminated clothin g and tools into the house ; and being conscious of other points of contamination such as water and soil splatter. Employing these practices can reduce health risks especially for farmers but also their families. Additional surveys and workshops are suggested to gauge region al employment of safe irrigation practices. Public Awareness and Extension Services Most participants were engaged in the focus group and workshop suggesting that the topic i s important to them. One workshop participant commented that it reflected a typical agricultural extension seminar. In light of the lack of agricultural extension services in the region focusing on treated wastewater reuse it is recommended that additional workshops be cond ucted in and around Oued Souhil ( Bedo and Dooley, 2004 ). reported knowledge of human and en vironmental health risks warrant the implementation of regularly scheduled workshops to to health risks (Ndunda, 2013, p.1 1). These workshops should target farmers who i rrigate wi th treated wastewater and address the associated human health risks and methods of protection In fact, a ll workshop participants agreed that they are willing to attend another seminar presenting new information about treated wastewater reuse. Through disc ussion, safe irrigation practices can be realized and applied. It

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38 about treated wastewater reuse and safe irrigation practices. All workshops should be adapted arou nd low regional literacy rates to include visual representations of information. These recommended workshops c ould go one step further to address consumer health through discussi o n of sanitary crop harvesting and processing methods that work to prevent crop contamination T h is topic may be well received as this concern was voiced during the health and hygiene education workshop Additional workshops may b e conducted by GDA, CRDA, INRGREF or any other interested party. They should seek to include both men and women. For instance, conducting workshops in culturally appropriate mixed audience spaces may result in greater attendance by women. Holding workshops in the early afternoon, when most women are done with agricultu ral and household duties, may also result in increased attendance by women. Moreover the GDA office in Nabeul could display a large picture based poster for farmers that depicts health risks and associated recommendations for safe irrigation practices T his poster would be seen each time someone came to the GDA office to pay for treated wastewater It should be picture based in order to appeal to the many illiterate farmers in the region Finally, during this field practicum farmers asked to be informed about to what extent the ir wastewater had been treated. The frequency of information sharing will depend on the frequency of water testing. While this information will have to travel through a few stakeholders to be shared with farmers, it may re sult in safe irrigation practices due to heightened awareness of treated wastewater hazards. This information c ould be displayed at the GDA office in Nabeul. A chart illustrating the recently tested level of three or five progressive stages of water quality could be kept on display and adjusted accordingly The chart c ould use colors, numbers or faces

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39 to express water quality in order to accommodate illiterate farm ers. For example, green, yellow and red can reflect safe, hazardous and extremely hazardous water quality levels, respectively. Information sharing through posters and charts may increase safe irrigation practices in Oued Souhil. Additional Testing While treated wastewater reuse for irrigat ion presents benefits there is also risk of environmental damage. F armers involved in this study highly stressed their concern about the quality of their water and soil sources. I t is recommended that additional water and soil testing be carried out in Oued Souhil. Water collection p oints can include a random selection of farms, the Nabeul Storage Basin, and the SE3 and SE4 treatment plants. In addition, w astewater runoff can contaminate groundwater supply. Although there is no direct evidence of this happening in Oued Souhil, the general consensus of farmers is that well and groundwater are contaminated. T esting of well water may prove valuable in determining whether it is contaminated, with what, and if it is safe for agricultural use. Microbial analyse s of wastewater and groundwater allow for a better understanding of pathogens present. The World Health Organization (2006) also suggests carrying out epidemiological studies to measure diseases present in the exposed reg ion in order to better assess regiona l human health risks. Microbial bacterial and epidemiologic al analyses are recommended for Oued Souhil ; however, these tasks fall outside the realm of this field practicum Additional environmental risks may include salinization and contaminat ion of top soil layers The World Health Organization (2006) claims that salinization of soil and the presence of heavy metals and pathogens in topsoil are concerning environmental risks Ir rigation with treated wastewater exceed ing two or three decades has been found to result in high salinity levels and

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40 heavy metals in soils in some locations ( Siebe, 1995; Bouri 2008). The long term use of treated wastewater in Oued Souhil suggests that these risks may be present and warrants soil testing. Wastewater Treatment W astewater treatment plants in Nabeul are operating over capacity. To amend this problem, i t is recommended that the National Sanitation Office ( ONAS ) expand or enhance existing infrastructure C onstruction requires a c ost benefit analysis of various types of infrastructure and falls beyond the scope of this study Research about Animal Health Risks It is recommended that animal health risks associated with the ir consumption of and/or contact with treated wastewater and contaminated soil on the farmland be investigated. C hickens were seen drinking treated wastewa ter during irrigation during a field visit in Oued Souhil (F igure 1 6 ) Additionally, cows and other animals that graze on contaminated soil s are at risk for consu ming helminth eggs (WHO et al 2006). A second examination c ould follow this investigation to assess whether or not the consumption of these animals and their byproducts has a negative health impact on humans During the health and hygiene education workshop, farmers asked about animal health risks It is clear there is con cern about animal safety in Oued Souhil and fu rther research is desired. Figure 16 : A chicken drinking treated wastewater on a farmland in Oued Souhil

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41 Conclusion Treated wastewater reuse for irrigation in Oued Souhil Tunis ia has gained popularity since before the 1980s due to limited water resources in the region Treated wastewater may contain contaminants, thus protective measures should be employed during and after irrigation application to reduce health risks for farmers and their families. Use of protective equipment (i.e. boots, gloves and long pants ) minimiz es the risk for direct waste water contact. Du e to gaps in knowledge about these risks, however, the majority of farmers in Oued Souhil reported not using protective equipment w hile irrigating Increased employment of safe irrigation practices as well as po st irrigation hygiene practices m ay reduce health risks for farmers and their families in Oued Souhil Improving treated wastewater quality through various infrastructure improvements could also be nefit human health. Effective wastewater treatment will significantly reduce the amount of pathogens and bacteria in the final product, which will then reduce the amount coming into contact with farmers and their families F armers in this study highly stressed their concern about the quality of their water and soil sources. Additional water and soil testing as well as animal health research may reveal any associated envir onmental concerns in the region Enhanced agricultural extension and education services are needed in Oued Souhil to disseminate information on the safe use of treated wastewater for irrigation. By adapting these services around regional gender roles and norms, equal access by men and women can be supported. In Oued Souhil, both men and women work on the irrigated far m land and share responsibilities in decision making. Appropriately targeting education and extension services will help promote safe irrigation pra c tices. Information dissemination through workshops, posters c harts and subsequent word of mouth may increa se employment of protective

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42 equipment among current and future farmers in Oued Souhil, thereby reducing human health risks associated with treated wastewater reuse for irrigation. su pport s the conclusion that workshops will result in higher rates of awareness and motivation regarding safe irrigation practices among farmers in Oued Souhil Tunisia These improved irrigation practices rely on information sharing of treated wastewater q uality, associated health risks and measures for protection. The successful implementation of recommendations discussed will promote safe irrigation practices among farmers irrigating with t reated wastewater in Oued Souhil thus work ing to reduce associated health risks for farmers and their families

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43 Bibliography Al Salem, S.S. & H. Abouzaid ( 2006 ) Eastern Mediterranean Health Journal 12(3/4): 446 58. Aljazeera and agencies (July 29, 2013) Aljazeera Retrieved from http://www.aljazeera.com/news/africa/2013/07/2013 7290235919298.html Amara, Tarek ( July 28, 2013 ) Reu ters Retrieved from http://www.reuters.com/article/2013/07/28/us tunis ia death idUSBRE96Q01Z20130728 Bedo, S hannon H., & K im E. Dooley (2004). Education, research and extension: An evaluation of agricultural institutions in Tunisia. Association for International Agricultural and Extension Education: Proceedings of the 20 th Annual Conference, 1996 2006 Retrieved from http://www.aiaee.org/attachments/article/1108/084.pdf Bouri, Salem, Habib Abida, & Hafedh Khanfir ( 2008 ) gation in arid and semi arid Environ mental Geol ogy 53: 1421 32. Central Intelligence Agency (CIA) (2012) Retrieved from https://www.cia.gov/library/publications/the world factbook/geos/ts.html. Coombes, Yolande & Jacqueline Devine (2010) Introducing FOAM: A Framework to Analyze Hand washing Behaviors to Design Effective Hand washing Programs. Water and Sanitation Program, World Bank Eds. Croitoru, Lelia & Maria Sarraf (2010) Cost of Environmental Degradation: Case Studies from the Middle East and North Africa Wa shington, D.C.: World Bank Do Thuy Trang et al ( 2007 ) Tropical Medicine and International Health 12: 51 58. Elizabeth Day ( May 14, 2011 ) The Observer Retrieved from http://www.guardian.co.uk/world/2011/may/15/arab spring tunisia the slap. Ensink, Jeroen H. J. & Wim van der Hoek ( 2007 a ) Tropical Medicine and International Health 12(5): 575 577. Ensink Jeroen H. J., Tariq Mahmoud, & Anders Dalsgaard ( 2007 b ) irrigated vegetables: Tropical Medicine and International Health 12: 2 7. Eds. Feldstein, Hilary Sims, & Susan V. Poats (1989) Working Together: Gender Analysis in

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44 Agriculture. C onnecticut: Kumarian Press Eds. Feldstein, Hilary Sims, & Janice Jiggins (1994) Tools for the Field: Methodologies Handbook for Gender Analysis in Agriculture. C onnecticut: Kumarian Press Food and Agriculture Organization (FAO) (2012) Tunisia Overview Retrieved from http://faostat3.fao.org/home/index.html#VISUALIZE _BY_AREA. Frija, Aymen, et al ( 2009 ) Agricultural Water Management 96(11): 1509 1516. Harris, Ray & Khalid Koser (2004) Continuity and Change in the Tunisian Sahel. England and USA: Ashgate Publishing. IRESA (2004) Retrieved from www.iresa.agrinet.tn/fr/instit/p_inrgref .htm. Kenneth J. Perkins (2004) A History of Modern Tunisia. United Kingdom: Cambridge University Press La treille, Martin ( 2008 ) Rural Tunisia Int. J. Middle East Studies 40: 599 621. Mullin, Corinna & Ian Patel (Aug 5, 2013) Political violence and the efforts to salvage Aljazeera Retrieved from http://www.aljazeera.com/indepth/opinion/2013/08/20138310271198303.html National Research Institute in Rural Engineering, Water and Forestry (INRGREF) (2014). [ Perceived and actual w ater and soil effects of long term treated wastewater reuse in Oued Souhil, and assessment of regional use of protective equipment by farmers.] Unpublished raw data. Ndunda, E.N. & Mungatana, E.D. ( 2013 ) Open Science Repository Natural Resources and Conservation Retrieved from O nline O pen A ccess, e70081917. Doi:10.7 392/Research.70081917. OECD (2012), OECD Investment Policy Reviews: Tunisia 2012, OECD Publishing. Retrieved from http://dx.doi.org/10.1787/9789264179172 en. Okoh, Anthony I., Thulani Sibanda, & Siyabulela S. Gusha ( 2010 ) International Journal of Environmental Research and Public Health 7: 2620 37. Salem, Imen B., Imen Ouardani, Mouna Hassine, & Mahjoub Aouni ( 2011 )

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45 and physico chemical assessment of wastewater in different region of Tunisia: Impact on BMC Re search Notes Schissel, Howard (1984) Facing a Future without Bourguiba. Af rica R eport Periodicals Archive Online : 68 71 Siebe, Christina & Enrique Cifuentes ( 1995 ) International Journal of Environmental Health Research 5(2): 161 73. Vuong Tuan Anh et al. ( 2007 ) urban aquatic Tropical Medicine and International Health 12: 59 65. World Health Organization (WHO), United Nations Environmental Program (UNEP) & Food and Agricultural Organization (FAO) (2006) WHO Guidelines for the Safe Use of Wastewater, Excreta and Greywater Volume II: Wastewater Use in Agriculture Geneva, Switze rland: WHO Press

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46 Appendices Appendix I: Deliverables Appendix II: Timeline Appendix III: Baseline Survey App endix I V : Structured Participant Observations Appendix V : Focus Group Discussion Questions Appendix V I : Sex Disaggregated Daily Routine Activity Sheet Appendix V II : Sex Disaggregated Community Resource Analysis Activity Sheet Appendix V II I: End of workshop Survey

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47 Appendix I: Deliverables The following points represent the anticipated deliverables and answered questions of this field practicum: 1. Analysis and social assessment of the wastewater reuse process for irrigation, accounting for impacts on human and environmental health. Have the health risks of this practice been researched and revealed and have associated unsafe health behaviors been addressed? 2. Gender disaggregated data about agricultural roles. Have regional gender roles been analyzed within the context of treated wastewater reuse? 3. Health workshop addressing and promoting proper WASH practices conducted and documented. Materials supporting proper WASH practices developed. Have risky health behaviors improved? 4. Final in country presentation to stakeholders detailing practicum results. 5. Two final presentations (a poster and a defense) to UF stakeholders and community members detailing the objectives, activities, methods, and results of field practicum. Final report submitted by Apr il 2014.

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48 Appendix II: Timeline Pre departure January : Submit draft proposal and secure funding February : Begin communication with host organizations and in country supervisors; Submit IRB application March : Revise IRB if necessary; Purchase airline tick ets; Secure housing and other in country logistics April : Submit finalized proposal; Receive funding; Submit IRB approval; Secure in country housing and other logistics May : Depart for Tunisia on May 8, 2013, and arrive on May 9 In country Week 1 (May 10 17) : Meet with all stakeholders in various settings to reaffirm project goals and refine methodological approaches; Obtain and compile all existing survey and gender disaggregated data; Tour wastewater reuse facility; Meet with collaborators Weeks 2 6 (May 20 June 21) : Conduct baseline surveys; Host focus group discussion with health discussion and gender based activities; Process data; Develop health and hygiene education workshop and materials Week 7 (June 24 26) : Conduct health and hygiene education work shop; Evaluate immediate impact of workshop by conducting assessment survey at end of workshop Week 8 (June 27 July 7) : Data processing; Prepare follow up survey for future undertaking Weeks 9 11 (July 8 26) : S ubmit follow up survey ; Data translation, proc essing and interpretation; Prepare and submit final presentation for review; Submit brief report of objectives and activities to INRGREF Week 12 (July 29 31 ) : Share practicum results to stakeholders and present a sustainable and adaptive response to observed and discussed problems, and receive feedback Post departure October 11, 2013: Present comparative analysis of gender roles in Tunisia, Morocco and Jordan at CIES regional conference October 29, 2013: Present poster to UF and community detailing objectives, methods, results, conclusion, and implications December 4, 2013 : Present poster to UF and community members detailing objectives, methods, results, conclusion, and implications; Draft report submitt ed to all stakeholders April 2014 : Defend field practicum at UF with stakeholders a nd community members; Submit final report of field practicum to all stakeholders; Present field practicum objectives, methods, results, conclusion, and implications at vario us conference s

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49 Appendix III: Baseline Survey Researchers: Raina S. Zantout; __________________________________________ Survey number: _____________________________________________________ Language of survey: __________________________________________________ Name of person surveyed: _____________________________________________ Relationship to land owner: ___________________________________________ Demographic Information 1. Is your house on the irrigated land? Yes / No If no, do you have any facilities on the land? Yes / No 2. What are the highest levels of education for the following: Household head male Household head female Children Grandparents Other persons 3. Who manages the family budget? Treated Wastewater and Agricultural Products 4. What do you grow? 5. Do you use fertilizer, manure, both, or other? 6. From where do you secure fertilizer/manure/other? Purchase at _________________________ From livestock Other source_________________________ 7. Who gets it? 8. Who pays for the treated wastewater? 9. Have you noticed any changes in the quality of this water? Yes / No Odor Color Froth Turbidity Other ______________________ 10. For how much time do you stop irrigating before ha rvesting crops? 11. Who takes care of the crops? (Including harvesting, cleaning, treating, processing, selling, and cooking) 12. What do you do with these crops? Sell Consume

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50 Process and consume Process and sell Other 13. Do you think the taste of the fruits has changed since irrigating with treated wastewater? Yes / No If yes, why? ___________________________ 14. Who decides which crops to plant? Land owner Household head male Household head female Other ______________________ 15. Where do you buy seeds and plants? G DA Cooperative Private Other _______________________ 16. Who tends to the land in your absence? WASH: Water, Sanitation and Hygiene Information 17. What types of illnesses can we get from treated wastewater? Nothing Skin Stomach Diarrhea Allergies Worms Other __________________________ 18. Do you or your family members have one or any of these illnesses? Yes / No If yes, which one(s)? _______________________________ 19. Have you or they received treatment? Yes / No If yes, what is it? ______________________ ____________ 20. Do you have access to potable water on the farmland? Yes / No If yes, how? Well water Tap water Other ________________ 21. Do you drink this water? Yes / No If no, why? ___________________________ 22. Once you are finishing irrigatin g for the day, which precautions do you take in order to not contaminate your house? Take a shower Wash hands Wash face Wash boots Leave boots outside

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51 Wash gloves Leave gloves outside Wash clothes Leave clothes outside Other ___________________________________ 23. What type of soap do you use to wash your hands? Nothing Liquid Soap Locally produced green bar soap Other _______________ 24. Normally, when do you wash your hands? After finishing irrigating for the day After irrigating Af ter treating livestock Before eating After using the toilet Other _______________ 25. What precautions do you take after treating your livestock? Other 26. Do you accept that we pass one afternoon on the farmland and with your family to document uses of treated w astewater? Yes / No When is most convenient? ________________________________________ 27. Are you interested in participating in a discussion about health? Yes / No When are you free? _____________________________________________ 28. ( To ask females only ) Are you interested in participating in a discussion about agricultural activities? Yes / No When are you free? _____________________________________________ 29. Are you interested in participating in a seminar about health and hygiene? Yes / No If the seminar falls during Ramadan, during which moment of the day are you free? ____________________________________________

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52 Appendix I V : Structured Participant Observations Mark for yes The farmer is wearing gloves The gloves are dirty The farmer is wearing boots The boots are tall enough The treated wastewater is brown The treated wastewater is light brown The treated wastewater is clear The treated wastewater has a strong smell There are human health risks present Such as: Other comments :

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53 Appendix V : Focus Group Discussion Questions 1. What do you think about treated wastewater reuse? Why do you use treated wastewater for irrigation? 2. Do you think this water can transmit illnesses? What types of illnesses do you think we can get from this water? How can we contract them? What precautions can we take to prevent these illnesses? Since you began using treated wastewater, what health problems have you noticed in your household or neighbo rhood? 3. What precautions do you take when eating or drinking on the farmland? Why? 4. What do you do with your clothes, boots, gloves, etc., when coming home? Why? 5. Are you worried that you will become sick after coming into contact with the treated wastewater, cooking with dirty hands, or using the toilet? Why do you think to wash your hands at these moments? 6. Do you think the oth er agriculturalists do like you and/or your husband? Finally, what recommendations do you have for other agriculturalists who irrigate with treated wastewater?

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54 Appendix V I : Sex Disaggregated Daily Routine Activity Sheet

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55 Appendix V II : Sex Disaggregated Community Resource Analysis Activity Sheet

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56 Appendix V II I: End of workshop Survey Researcher: ___________________________________________________ Name of person surveyed: _______________________________________ 1. Did this seminar change your idea about treated wastewater? What changed? 2. What do you think about the human health risks we discussed? Were any of these risks new? 3. What do you think about the exposure methods we discussed? Were any of these methods new? 4. What do you think about the best irrigation practices we discussed? Were any of these practices new? Will you now think about wearing boots, gloves and long pants? 5. Do you accept that we return to ask you more questions? During Ramadan, which time of the day is best?