A Conceptual Model to Assess the Literacy of Water Consumers

1. Introduction

The water that exists in nature contains microorganisms that may be pathogenic for humans (Bagchi2013). Considering the key role that water plays in disease prevention and health promotion, the issues that are related to water literacy can also be related to health literacy. The World Health Organization (WHO) defines health literacy as the set of cognitive and social skills that determine individual motivation and skills, and enable access, understanding and the use of information in health promotion. In this way, citizens should have a level of knowledge and skills to support conscious decision-making, leading to changes in behavior and ways of living, with a view to improving health from an individual or public perspective (World Health Organization1998). For this reason, the concern with the determination of the parameters of water quality for human consumption has been growing in Portugal. The number of accredited laboratories is increasing, and the existence of Quality Management Systems can contribute to raising the level of services provided and to enhancing customer satisfaction which, on the other hand, may be aware of, viz.

The main objective of this work is to develop a conceptual model that can support studies related to the water quality issues. In this work, the level of knowledge of consumers about water quality was chosen to demonstrate how the proposed model can be applied to real-world problems. Thus, based on the conceptual model, a questionnaire to examine the level of knowledge of consumers regarding water quality was developed and applied to an opportunity sample involving 147 individuals.

2. State of the Art

A literature search was carried out to identify key concepts, theories, sources of evidence and knowledge gaps. The five steps described by Arksey and O’Malley (2005) (i.e., identifying the research question, identifying relevant studies, selecting studies, plotting the data and finally, grouping, summarizing and reporting the results) were followed.

A bibliographic search was carried out in the ScienceDirect and B-On platforms using the keywords like literacy, awareness, water, water for human consumption, drinking water, the environment, disease prevention and public health.

The search for the term literacy gave a result of 304,319 (Figure 1). The studies related to consumer literacy in the areas of finance (Cameron et al.2014; Kramer2016) and health (Amoah2018; Balmer et al.2020) are more frequent than the ones concerning environment and water. A study carried out by Amoah (2018) demonstrated that participations in social activities (religious, voluntary and in-groups) and health literacy have positive effects on the health and well-being. Data were collected through the distribution of 779 questionnaires to rural and urban residents in the Ashanti Region of Ghana, from June 2015 to October 2015. Balmer et al. (2020) studied the connection between the literacy levels of nursing students over the years of their training in four regions of the world. The data were collected between 2014 and 2016, enrolling 845 nursing students. In all regions, the results show significant changes in health literacy profiles according to the training year, namely in the ability to find good health information.

The association of the terms $\mathrm{\text{literacy}}+\mathrm{\text{environment}}$ and $\mathrm{\text{literacy}}+\mathrm{\text{water}}$ allowed to identify 13 works (Figure 1). After discarding the duplications, 12 papers were considered. Their analysis shows that five of them are related to environment, but in a perspective different from the one intended in this study. Ramdas and Mohamed (2014) define the concept of environmental literacy not only as the knowledge about the environment and its problems, but also as the one related to attitudes, sensitivity and motivation. Having this in mind, the authors addressed the problem of tax application to tourists to change their environmental behavior. The study shows strong associations between tourists’ level of environmental literacy and willingness to pay for environmental conservation (Ramdas and Mohamed2014). Broek (2019) studied the household energy literacy. The author highlighted that consumers with positive environmental attitudes and with higher education demonstrate greater levels of energy-saving literacy. Craig and Allen (2015) studied students’ environmental literacy and energy-saving behaviors. Goldman et al. (2018) investigated the environmental literacy of students and the environmental performance of schools with certification. Sovacool and Blyth (2015) studied the Danish consumer literacy in issues related to affordability of electricity and gasoline, climate change and their preferences to alternative energies.

From the set of selected papers, only seven were associated with the terms literacy and water. However, only one presented a study regarding water quality literacy. Irvin et al. (2019) studied the level of knowledge of well owners about the risks associated with the use of water from private sources, particularly regarding environmental pollution or the presence of contaminants. The rest of the works deal with the terms literacy and water from a different perspective than this study. He (2018) analyzed the Chinese literacy regarding the use of water as a resource that must be preserved. The author evaluated the current status of water literacy across different geographic areas of China, in order to develop a methodology to establish reasonable water-usage policies. Roldán et al. (2019) investigated students’ climatic literacy to identify the relationship between the problem of water and the climate crisis. Simonds et al. (2019) studied the literacy of the risks associated with the consumption of contaminated water in some rural communities in the United States. Seelen et al. (2019) carried out a study on the level of knowledge regarding the factors that can threaten water quality (agriculture, industry and climate change). Su et al. (2011) studied the level of literacy related to the impacts on public health resulting from catastrophes associated with intense rain phenomenon. Finally, Bhardwaj et al. (2017) investigated the percentage of people in India who practice defecation in the open sky. The authors investigated the different factors which were responsible for the non-usage of toilets in India and explored the drainage system and sanitation conditions in public places. According to the authors, the low education levels (particularly of women) and the lack of awareness regarding the ill-effects of open defecation are mainly responsible for not using toilets in India.

3. Methods

3.1. Water Consumption Literacy model

Considering the importance of water quality for health and the paucity of literature on this topic, a conceptual model for the study of Water Consumption Literacy (WCL) was developed and presented in this paper (Figure 2). In this model, the main dimensions of WCL (i.e., Water Quality, Disease Prevention and Public Health Promotion) are presented within the pentagon. These dimensions evolve from an individual-centered perspective (inner pentagon) to a population-focused one (outer pentagon). In each dimension, four competencies should be investigated, i.e., Access, Understand, Appraise and Apply information related to water consumption. Access is related to the ability to seek, find and obtain information. Understand refers to the ability to cognize the information found. Appraise is linked with the individual’s ability to interpret, filter, judge and evaluate information. Finally, Apply refers to how information is used and shared (Sørensen et al.2012). The factors that can influence the dimensions described above are the literacy of consumers on the subject, the recognition of the need to consume controlled water, the existence of accredited laboratories and the existence of water treatment services. Such factors go forward from a person-centered perspective to a community-focused one. Thus, the proposed conceptual model considers literacy for water consumption in a broader perspective aiming to contribute to global sustainability.

3.2. Participants

The study was carried out in the Water Laboratory of Santiago do Cacém, located in Alentejo Litoral, belonging to the district of Setúbal, Portugal. An opportunity sample including 147 participants aged between 18 years and 82 years with an average age of $41\pm 23$ years was used. Participants’ age was categorized into age groups, i.e., under the age of 25 years, 26–50 years, 51–70 years and above the age of 70 years. Here, 38.1% of participants are aged between 26 years and 50 years of age, 29.2% between 51 years and 70 years of age, 19.8% are under 25 years of age, whereas 12.9% are above 70 years of age. The gender distribution included 46% of men and 54% of women. Concerning academic qualification, 14.3% of the participants expressed to have completed only basic education, 55.1% declared to have concluded secondary education, 25.8% stated to have finished a degree and 4.8% affirmed to have a post-graduate level of education.

3.3. Data collection

Taking into consideration the pros and cons of the distinct data collection techniques (McMillan and Schumacher2009; DeKetele and Roegiers2016; Cohen et al.2017), the questionnaire survey was selected. The underlying reasons for this choice are associated with the fact that this tool (i.e., the questionnaire survey) has a clearly defined structure and makes it possible to transform the qualitative information given by the respondents into quantitative data.

The questionnaire (Appendix A) was organized into two sections. The former one includes general questions (e.g., age, gender and academic qualifications), whereas the second one comprises 16 questions related to water literacy, covering the three dimensions referred in the WCL model (Figure 2), i.e., Water Quality (six questions), Disease Prevention (five questions) and Public Health Promotion (five questions), considering the four essential competencies in information processing (i.e., Access, Understand, Appraise and Apply) as presented in Table 1. In the first section, the answers are descriptive, whereas in the second one a Likert scale with four levels (i.e., very easy, easy, difficult and very difficult) was used. The main reason that motivated the use of this scale was related to the expected sample dimension. In the second section, the participants were asked to indicate the degree of difficulty they felt in performing relevant tasks related to water quality and their impact on health. It should be noted that this is an instrument that aims to access the water consumers’ literacy based on self-perception.

The questionnaire was validated according to Bell (2010), i.e., it was evaluated by three experts who suggested some corrections. After including the experts’ suggestions, the questionnaire was applied to a small group of participants (not included in the sample) to assess its validity and identify difficulties in interpreting the questions. In order to estimate the reliability of the instrument, the Cronbach’s alpha was computed. The value obtained for the 16 questions included in the second section of the questionnaire was 0.81.

Data collection was carried out between September 2020 and January 2021. To prevent potential hidden errors related to the ostensibly random sampling methods that can lead to biased results (Shang2019), all customers were asked to fill out the questionnaire. The response rate was 80% (147 questionnaires received from the 183 administered).

3.4. Ethical aspects of the study

The respondents took notice of the goals of the questionnaire and participated voluntarily, without any pressure or coercion. The study was performed in conformity with the applicable laws and institutional guidelines and was approved by the quality manager of the Water Laboratory of Santiago do Cacém. Moreover, the participants gave an informed consent to participate in the study.

4. Results and Discussion

Figure 3 displays the frequency of answering to the second section of the questionnaire, where the respondents expressed their opinion on the groups of questions regarding each WCL dimension (Table 1). The questions Q1–Q6 refer to the Water Quality, Q7–Q11 are related to Disease Prevention and Q12–Q16 are related to Public Health Promotion. Concerning Water Quality, the analysis of the frequency of answers [Figure 3(a)] showed that the overwhelming majority of respondents, varying between 75% and 97.5%, selected the option of difficult or very difficult. These results reveal the low literacy level of the respondents about water quality topics, regardless of the competence investigated (i.e., Access, Understand, Appraise or Apply).

Aiming to find the trends, regularities or patterns in the responses obtained in the second section of the questionnaire, the binary associations between the responses were also studied. In order to make the analysis easier, the responses denoting higher levels of literacy (i.e., very easy and easy) were classified as Positive ($P)$. Conversely, the responses that reveal lower levels of literacy (i.e., very difficult and difficult) were classified as Negative ($N)$. The results obtained (Table 2) show that 75% of respondents report having difficulty in accessing (Q1) and in understanding (Q3) information about the results of the water analysis of the public network. Only 1.5% state that they do not have difficulty. Concerning the water quality control of private water abstractions, 67% of respondents reveal difficulty in accessing (Q2) and understanding (Q4), 79.5% in accessing (Q2) and appraising (Q5), 69% in accessing (Q2) and applying (Q6), 77% in understanding (Q4) and appraising (Q5), 58.5% in understanding (Q4) and applying (Q6) and 73.5% in appraising (Q5) and applying (Q6). Only a percentage of respondents ranging from 1% to 13% declare that they have no difficulty in performing these tasks.

The results obtained in this dimension are in concordance with various authors who point out that the majority of well owners do not analyze their water despite being concerned with the environmental pollution issues (Knobeloch et al.2013; Gibson and Pieper2017; Maleckia et al.2017). Furthermore, they also agree with studies that highlight that the population has difficulties in interpreting the water quality reports (Kreutzwiser et al.2011; Fox et al.2016; Maleckia et al.2017).

The results related to Disease Prevention [Figure 3(b)] reveal a slightly higher level of literacy than that obtained in the previous dimension. Indeed, in all questions of this group (except Q10), the option very easy or easy was selected by a percentage of respondents ranging between 29.5% and 72.5%. With respect to Q10, related to appraising whether a particular symptom is related to the use of untreated water, an overwhelming majority of respondents selected the option of difficult or very difficult (96%).

The analysis of the binary associations regarding Disease Prevention (Table 2) reveals that 41% of the respondents declare having facility in accessing (Q7) and understanding (Q9) the health risks associated with the use of untreated water. Conversely, 56.5% assert to have difficulties in achieving these tasks. Regarding the symptoms of diseases associated with the use of untreated water, 69% of the respondents declare having difficulty in accessing (Q8) and appraising (Q10) these symptoms, whereas 2.5% declare facility in these topics. Also, 22.5% of respondents reveal to have facility in accessing (Q8) and applying (Q11), whereas 20.5% reveal to have difficulties. Only 4% affirm to have facility in appraising (Q10) and applying (Q11), whereas 27.5% state to have a difficulty. A percentage of respondents between 50% and 68.5% declare to have facility in applying the instructions given by health professionals (Q11) although they declare to have difficulty in accessing (Q8) or in appraising (Q10) the symptoms. These results show that the respondents can follow the instructions of health professionals in spite of having low levels of literacy in this topic (i.e., symptoms of diseases associated with the use of untreated water).

The difficulty to appraise whether a symptom is related to the consumption of untreated water was identified in several studies and is associated with the absence of tests or treatment of the water of private abstractions. The reasons stated by the owners are related to the fact that the water from private abstractions smells, looks and/or tastes fine (Imgrund et al.2011; Flanagan et al.2016; Stillo and Gibson2017). This is a very serious problem since some contaminants like arsenic, nitrate and/or lead are not detectable by taste, smell and/or color. This picture is worsened by the latency period between the cumulative exposure and adverse health effects (Rubin et al.2013). Thus, appraising the possible cause–effect relationship between untreated water consumption and the health symptoms is a very difficult task for the population.

Finally, regarding Public Health Promotion [Figure 3(c)], the options selected by the respondents reveal a higher level of literacy. In fact, the percentage of respondents who chose the option very easy or easy varies between 60.5% and 83%, except in Q16, where this percentage was lower (36%). Despite the fact that the respondents state to be able to apprise if their lifestyle contributes to sustainable water use (Q15), they reveal ineffectiveness to apply actions to save water in their daily life (Q16).

The results concerning binary associations related to sustainable water use present in Table 2 show that 67% of the respondents claim having facility in accessing (Q12) and understanding (Q14), 57.5% in accessing (Q12) and appraising (Q15), 32% in accessing (Q12) and applying (Q16), 56% in understanding (Q14) and appraising (Q15), 30.5% in understanding (Q14) and applying (Q16) and 28% in appraising (Q15) and applying (Q16). However, a percentage of respondents ranging from 13% to 31.5% declare that they have difficulty regarding these issues. Thus, raising the awareness of the population, especially the youngest, for the sustainable use of water is essential. In accordance with these results, Yu et al. (2021) emphasize that people having high level of water literacy develop water-saving practices (e.g., notify the competent authorities to repair water facilities). According to the authors, the promotion of water knowledge can contribute to decreasing the consumption of water. However, the study concluded that despite the correlation between water responsibility and ecological management actions, consumer economic actions and citizens’ actions, the impact is still small. Indeed, the promotion of this type of behavior is difficult due to economic factors, lack of time and limited mobility. The authors suggest that the promotion of positive attitudes regarding water is a requisite to achieve the water conservation goals and recommend the authorities to subsidize water-saving devices and products.

A global analysis of the results presented in Figure 3 and Table 2 allows to state that in Water Quality and Disease Prevention dimensions, the competence where the respondents reveal the greatest difficulties is Appraise. In other words, respondents reveal difficulties in assessing the effectiveness of the solutions/information. Regarding the remaining dimension (i.e., Public Health Promotion), the respondents reveal the greatest difficulties in the competence Apply. These results are in line with those obtained by some studies which highlight the fact that the owners of private abstractions must be able to find, in an autonomous way, a multiplicity of information regarding the maintenance and stewardship of private water abstractions. In fact, owners of private abstractions must access, understand, appraise and apply information about a multiplicity of water-related issues (e.g., chemical and bacterial pollutants that can pose a health hazard or the water treatment strategies to implement). A difficulty that has been identified is related to the individual’s ability to find, understand, appraise and apply water quality information. Water quality reports and analytical results often include complex terms, labels and numbers with various units that can be difficult to interpret, contributing to the low rates of private water testing and treatment (Kreutzwiser et al.2011; Fox et al.2016; Maleckia et al.2017). Bearing in mind this set of results, there are some measures that can be proposed and implemented at the local level, to promote consumer literacy. Among them can be mentioned the dissemination of water quality results in local newspapers and municipalities, accompanied by simple and intuitive explanations. In addition, training actions on water quality (e.g., frequency of analyses, parameters to be analyzed and reference values) and on the role of water in disease prevention and health promotion can be carried out. These trainings could take place in schools (aiming at a young population) and in community institutions (aiming at the population in general).

The WCL model presented in Figure 2 aims at human well-being and the promotion of quality of life of citizens. Indeed, the concept of quality is inherent to human beings, and it is implicit in the daily life acts (Hoyle2017). During the 1950s and 1960s, the concept of total quality management was developed. According to this philosophy, quality became to be seen as a problem of the company and not exclusively of the production or the product. This paradigm shift took Deming, in 1980s, to propose the PDCA (Plan, Do, Check and Act) model. This model, also known as the Deming Cycle, consists of a sequence of four repetitive steps of improvement and learning, i.e., Plan, Do, Check and Act as shown in Figure 4. Plan consists in identifying and analyzing the problem. Do includes the development and testing of the potential solutions. Check consists in assessing the effectiveness of the solutions and analyzing the improvements. Finally, Act refers to the implementation of the improved solutions (Hoyle2017).

The PDCA model (Figure 4) and the conceptual model for WCL (Figure 2) aim to achieve excellence, through the evaluation of the current reality, and, from there, to identify new solutions that lead to process improvements. Thus, it is possible to interrelate them by matching the competencies Access and Understand to the Plan and Do phases, the competency Appraise to the Check stage and, finally, the competence Apply to the Act step (Figure 5). Indeed, both models aim to promote organizational efficiency and customer satisfaction through the reinforcement of their literacy. The knowledge acquired by them can lead to good practices and to contribute to the desired global sustainability. The articulation of the WCL and PDCA models will support future studies related to consumers (e.g., assessing literacy levels in relation to water issues), organizations operating in this sector (efficiency studies) as well as public policy formulation and/or implementation. In fact, the global management of water resources should be regarded in a holistic perspective, taking into account different viewpoints, ranging from water quality to the multiple dimensions of water governance [e.g., integrated management (Claassen2013; Wang et al.2018), evaluation/implementation of water guidelines (Akinsete et al.2019; Apostolaki et al.2019; Giakoumis2019), stressing conditions (Hartley et al.2018; Horne et al.2018; Tortajada et al.2019) and water reuse (Hartley et al.2019; Rebelo et al.2020; Takeuchi and Tanaka2020)], including the connection between water and health.

5. Conclusions

Despite the high number of papers on literacy, this work identified a paucity of papers on literacy studies related to the quality of water for human consumption. Considering the risks to health associated with the consumption of inappropriate water, it is mandatory to evaluate the population’s literacy levels on these issues. Thus, the scarcity of information on the topic and the importance of water quality for health have led to the development of the conceptual model presented in this study. Such model can be of utmost importance to support studies aiming to assess water consumers’ literacy. The articulation of the developed model (WCL) and the PDCA model allowed to build a questionnaire that was applied to a cohort of 147 respondents in order to evaluate the literacy of the consumers regarding the quality of the water issues. The main contribution of this work is to present a methodology that can contribute to assess/promote water literacy, organizational efficiency and consumer satisfaction, leading to good practices that contribute to public health and global sustainability. The main limitation of this study is related to the sample size. The number of participants was conditioned by the use of an opportunity sample. In future work, the questionnaire should be expanded to include other questions in order to extend the literacy studies. In addition, the sample should comprise general population, beyond the water laboratory consumers. The use of a large and diversified sample will allow to study the influence of socio-demographic characteristics on the level of knowledge of the water consumers about water quality.

The articulation of the WCL model and an organizational tool like the PDCA model aims to achieve excellence through the evaluation of the current reality to promote improvement solutions, in a global perspective, that leads to a sustainable water management. In fact, both models aim for continuous improvement and intend to make the processes clearer and more agile. The conceptual model presented in this study can be used in all types of organizations and different geographic locations. To achieve this goal, it is necessary to adjust the dimensions of the model to the type of organization and/or activity. In fact, a preventive and continuous use of the proposed model can help to identify possible improvements, through the systematic collection and analysis of data, avoiding impulsive decision-making and wastage of resources. Furthermore, to extend the application of the instrument to other geographic locations, it will be necessary to carry out a cross-cultural adaptation, ensuring the content equivalence.

Acknowledgments

This work has been supported by FCT – Fundação para a Ciência e Tecnologia within the R&D Units Project Scope UIDB/50006/2020 | UIDP/50006/2020 and UIDB/00319/2020.