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                           BANGALORE, KARNATAKA



    AND ADDRESS               1st Year MSC Nursing, Koshys College of
                              Nursing,No.31/1,     Hennur     Bagalur       Road,
                              Kadusonnappanahalli, Kannur Post, Bangalore-
2   NAME          OF     THE Koshys College Of Nursing
    INSTITUTION               Bangalore
3   COURSE OF THE STUDY 1st year MSC Nursing
    AND SUBJECT               Community Health Nursing
4   DATE OF ADMISSION TO       09-03-2011
5   TITLE OF THE TOPIC        A descriptive study to assess the knowledge
                              regarding hardness of water and its effects among
                              adults in selected rural areas of Bangalore with a
                              view to prepare a self instructional module



       Water is the prime necessity of life, without which, terrestrial animals and vegetable life must cease to exist.

Water helps the man in many ways that is it replaces loss of fluid from tissues; maintain fluidity of blood and lymph;

helps in excretion of waste products ; acts as a vehicle of dissolving food; helps in digestion and regulates body


       Mans life in this universe or on the moon will be impossible without water, which is a prime necessity of

life. Even the vegetable and animal kingdom will not thrive without water. Without clothes, shelter, sometimes even

without food man can live but without water he soon dies.2

       Next to oxygen, water is the most important factor for survival of man and animals. A person can do

without food for five weeks or more, but without water he can survive only for a few days. The ten basic kinds of

water by John R Christopher as hard water, boiled water, raw water, rain water, snow water, filtered water, soft

water, reverse osmosis, de-ionized water and distilled water.3

       The various uses of water include domestic use, public purposes, industrial purposes, agricultural purposes,

power production from hydropower and steam power and carrying away waste from all manner of establishments

and institutions. On domestic front water is required for drinking, cooking, washing and bathing, flushing of toilets,

gardening etc. Cleaning streets, recreational purposes and public parks are included in public purposes. In industries

water is used for processing and cooling. Water is thus an essential factor in the economic, social and cultural

development of a community. It can eliminate diseases, promote rural development and improve quality of life.4

       The basic physiological requirements for drinking water have been estimate at about 2 liters per head per

day. This is just for survival. The consumption of water, however depends upon the climate conditions, standard of

living and habits of people. A daily supply of 150-200 liters per capita is considered as an adequate supply to meet

the needs for all urban domestic purposes. In India 40 liters of water supply per capita per day was the set target to

be achieved in rural areas.4

        Much of ill health which affects humanity especially in the developing countries can be traced to lack of

safe and wholesome water supply. Water is not only a vital resource to all forms of life, but it has also a great role

to play in socioeconomic development of human population.4

       Hardness may be defined as the soap- destroying power of water. The hardness in water is caused mainly by

four dissolved compounds. These are calcium bicarbonate, magnesium bicarbonate, calcium sulphate and

magnesium sulphate. Chlorides and nitrates of calcium and magnesium, iron, manganese and aluminium compounds

can also cause hardness but they occur generally in small amounts .4

       Water from any source including ground water, water from aquifers etc. that contain more than 1 GPG

(Grains Per Gallon) of dissolved hard minerals is called hard water. This hard mineral could be calcium,

magnesium, carbonate, manganese etc. In general water with 0 to 3.5 GPG is considered safe and soft. Anything

above this is considered hard water.5

       Hardness is not a specific constituent of water. It is primarily due to the presence of calcium and magnesium

in water. Hardness is expressed in terms of calcium carbonate (CaCO3). Water with less than 75 milligrams per liter

is considered soft, 76-150 mg/l is moderately hard and above 150 mg/l is hard water.6

       Hard water can cause many problems. While bathing if one is using shampoo and soap he will have to rinse

more thoroughly. Sometimes the soap remains on the skin even after bathing that can clog skin pores and can cause

rashes and other skin problems. Hard water with minerals such as iron and manganese has undesirable odor and

taste. Other health problems include calcium and magnesium in hard water reacts with soap and detergent and

diminishes their lathering and cleaning capability and form a scum, scales and lime deposits can damage the home

**Note: GPG: Grains Per Gallon
appliances and add to their repair cost, in the kitchen hard water can leave spots on dishes and cookwares and the

most common problem is in home plumbing. When hard water is heated, the dissolved hard water minerals re-

crystallize and form scale that can clog plumbing system and reduce flow of water through pipes.5


       One of the important public health care element is safe drinking water sanitation. More than a billion people

in developing countries lack access to safe drinking water.1

       Water is a good solvent and picks up impurities easily. As water moves through soil and rocks, it dissolves

very small amount of minerals and holds them in solution. Dissolved calcium and magnesium are the two most

common minerals that makes water hard. The degree of hardness become greater as the calcium and magnesium

content increases.7

        Hard water scum will not rinse from clothing and bed linen properly so that there is a disadvantage of these

residuals being in contact with delicate skin 24 hrs a day. Thus hard water can cause high levels of discomfort.8

        Water hardness is associated with higher incidence of urolithiasis among the population supplied with such

water. Urolithiasis is the formation of urinary calculi or stones in the bladder or urinary tract. It involves multiple

factors such as intake of liquids, genetic predisposition, eating habits, climatic and social conditions, gender etc.

Since the high magnesium content coupled with a high sulphate content can cause diarrhea, there is higher incidence

rates of cholelithiasis, urolithiasis, arthrosis and arthropathies with hardness of water.9

       A trace amount of fluorine in drinking water is essential for healthy teeth and bones; lack of fluorine causes

dental caries, while excess fluorine causes fluorine toxicity or fluorosis. Mild forms of fluorosis is manifested by

mottled teeth and the more severe forms are manifested by enlarged bones thus weakening the teeth and bones.10

         Excess fluorosis can lead to skeletal fluorosis and dental fluorosis. In skeletal fluorosis the muscles become

stiff and the person cannot do his normal work due to deformity. In dental fluorosis the enamel loses its shine, the

teeth become tough and tinted. Thus the enamel becomes weak and ultimately it is lost.11
        It is also important that pregnant women imbibe no fluoride because it damages several brain functions or

hormones in fetus. It also alters behaviour of babies. There is an average IQ of eight points in children showing

fluorosis of teeth.12

        Hard water cannot be used in industries for it interferes with the manufacturing process and causes decrease

in the quality of the product. If used it may produce explosion of boilers when its deposit produce scales of unequal

thickness of their inner surface.13

        Hard water can also sometimes leads to dermatitis. Dermatitis is an inflammation of skin, and it is more

common in persons suffering from dry skin. It can irritate the condition or even initiate a flare-up. Thus the skin will

become unable to absorb moisture. The combination of hard water with a co-existing dermatitis condition can lead

to more frequent and severe outbreaks.14

        Availability of safe water in adequate amount in India is still a major problem even after 62 years of

independence. There is scope for research in engineering and chemistry to convert available resources of water to

deliver safe water. This supply and maintenance of safe drinking water is the basic requirement of public water.15

        Unsafe water is the largest contributor of illness and death in developing countries. Eighty percent of death

and diseases is related to water supply. Worldwide more than three million people die each year from water related


        Water is mankinds most precious resource and one of the most important necessities for existence of human

life. Without good water supplies people can succumb to all types of illnesses, the majority of which can take lives.

Thus the need of studying about drinking water is so important.17

        By these informations the investigator is motivated and took this opportunity to access the knowledge and to

provide some guidelines to adults regarding hardness of water and its effects.


       Review of literature is an integral component of research process. It enhances the depth of the knowledge

and inspires a clear insight into crux of the problem. It helps the researcher to know what data are available to

narrow the problem itself as well as the technique might be used.

       Review of literature for this study is divided under following headings:

      Studies and literature related to safe drinking water

    Studies and literature related to knowledge of hardness of water

      Studies and literature related to effects of hardness of water

Studies and literature related to safe drinking water:

               According to Peter H Gleick, the failure to provide safe drinking water and adequate sanitation

services to all people is perhaps the greatest development failure of the 20th century. The most egregious

consequence of this failure is the high rate of mortality among young children from preventable water related

diseases. He examined different scenarios of activities in the international water arena and provided three estimates

of the overall water related mortality likely to occur over the next two decades. He found that as the total population

grows, total water related deaths will grow annually.18

               Safe water is essential for life. Sadly 1.2 billion people around the world lack access to safe drinking

water and twice that many lack adequate sanitation. As a result the World Health Organisation estimates that 3.4

million people die every year from water related diseases. Many of these diseases can be prevented with appropriate

water treatment and proper sanitation and hygiene practices. The WSSD (World Summit on Sustainable

Development) adopted a comparable goal for improving the access to basic sanitation.19

Studies and literature related to knowledge of hardness of water:

               In United States, peoples’s consciousness about water quality was raised recently due to several

widely reported incidents of public drinking water endangering health and even, causing death. Thus realizing major

emerging health threat, federal agencies, The Center for Disease Control and Prevention (CDC) and the

Environmental Protection Agency (EPA) issued warnings last summer that immune-compromised people are at

great risk- drinking tap water. Such people are advised to boil their water, or drink well-tested bottled water.

Because of all the publicity, even people in good health, who are unlikely to suffer infection from tap water, now are

more concerned about their water quality. Many are considering bottle water and have treatment options.20

               A prospective cohort study was conducted using 235 households (647 individuals) randomly selected

from four rural hamlets. Data were collected by means of a self administered questionnaire, a self report diary of

symptoms and two drinking water samples. Twenty percent of household sampled and had found bacteria

Escherichia Coli (E coli) in drinking water. The people were unaware of the contamination of drinking water from

private wells. This study confirms of relatively high prevalence of bacterial contamination of private wells in rural


Studies and literature related to effects of hardness of water:

               A descriptive study was conducted for the analysis of protective effect of calcium and magnesium

concentration in drinking water in 538 municipalities of Comunidad Valenciana (Spain) from 1991 to 1998.This

study provides statistical evidence of relationship between mortality from cardiovascular diseases and hardness of

drinking water. This relationship is stronger in cerebrovascular diseases than in ischemic heart disease, is more

pronounced for women than for men, and is more apparent with magnesium than with calcium concentration levels.

The weak effects of these two covariates make it difficult to separate them from the influence of socioeconomic and

environmental factors.22

               Mortality from CHD during the period 1961 – 1995 in 365 rural areas of Finland was linked with

2131 drinking water fluoride determinations performed in 1958 using negative binomial regression, adjustments
made for sex, age, mean income of the resident commune and drinking water magnesium and calcium.: An inverse

J- shaped relationship was found between drinking water fluoride and CHD, the association being most pronounced

in the 1960s and leveling off consistently as a function of time. In 1961 – 1970 the adjusted mortality from CHD

was 22% lower in the fourth quintile of fluoride than in the first quintile but this deficit reduced to 13% in 1991 –

1995. The more widespread use of fluoridated tooth pastes, soft drinks, and certain food items since the 1960s may

have reduced the significance of drinking water as a source of fluoride.23

               Water hardness is a term used to define the number of ions contained in the water, especially quantity

sulphate, carbonate salts of calcium and magnesium. There is a larger amount of calcium and magnesium salts in

hard water samples. These minerals have very important functions in the human body. In this study, the importance

of hard water in terms of human health has been assessed under light of current information. The studies about the

preventive role of hard water in cardiovascular diseases, cerebrovascular diseases, stroke and many types of cancer

are viewed. Water which must be consumed as 2 liters per day is very important for human life. It’s advised that

water for consumption to have medium hardness. The hardness level of water is an aesthetic quality. Thus, in

populations having a taste for soft water, the effort of individuals to softer the network water provided by

municipalities using different equipments, in addition to their preference of soft water in plastic or glass bottles for

consumption could imply lack of benefit of hard water for population health and also bring out some risks in terms

of water hygiene.24

               In order to study relationship between water content, hardness and clinical appearance of cataract,

135 lenses were obtained from eyes undergoing extracapsular cataract surgery. The cataracts were assessed and

classified pre-operatively. Lens hardness were determined by a specially designed guillotine and water content was

measured by weighing the lens before and after desiccation. A regression analysis was carried out to look at the

variation of lens water content with hardness, degree of nuclear sclerosis, extent of cortical and posterior

subcapsular cataract, vacuolation and age. Multivariate analysis of data demonstrated a relationship between lens

hardness and lens water content, degree of nuclear sclerosis and age. An association could not be detected between

lens water content and age, degree of nuclear sclerosis, extent of cortical and posterior subcapsular cataract and

vacuoles. This study suggests that hardening of the lens is reflected by a respective decrease in water content.

Increased hardness is associated with coloration and advancing age.25

               The effect on the blood lead levels of residents in an area in which a soft plumbo-solvent water was

hardened is examined. Water lead levels fell after hardening was introduced whereas there was a small rise in water

lead levels in a control area monitored over the same time. The blood lead levels of residents fell after hardening and

the fall was slightly greater than would have been predicted on the basis of the change in water lead levels. This

suggests that lead is less well absorbed from hard water than from soft water. Following hardening there was a

significant fall in mean blood level of subjects living in houses which had initially had negligible amounts of lead in

water. This suggests that hard water may interfere with the absorption of lead from sources other than water.26

               Robert W Winner studied that the chronic toxicity of Cd was reduced by an increase in water

hardness from 58 o 116 mg/l; a further increase in hardness to 230 mg/l, however had no further effect on chronic

Cd toxicity. The most consistent and sensitive index of chronic Cd stress was the abortion of young. Based on this

index, 0.75 to 1.50 mg/l humic acid had no effect on the chronic toxicity of Cd in either the soft or medium –hard

test waters. In conjunction with Cd exposures greater than the chronic no-effect concentration, the addition of either

0.75 or 1.50 mg humic acid per liter to water of any of the hardnesses usually increased mortality rate over a 42-day

exposure period. The mechanism by which humic acid increases abortion rate in hard water and increases mortality

rate in soft, medium-hard and hard water is unknown.27

               Community wells in rural areas of the San Miguel de Allende Municipality were tested between

September 2005 and February 2006 to determine the contamination from arsenic, fluoride and coliform bacteria.Of

the 101 water samples analyzed, 20 exceeded he Mexican government drinking water standard permissible limits for

fluoride levels and 69 tested positive for coliform; no fecal coliform was detected. The arsenic levels at all sites

sampled were below the Mexican government drinking water standards and do not pose a health risk. More than

100000 people reside in the rural areas where testing was conducted and they all depend on ground water for their

drinking water. As the ground water supply in this region diminishes due to overuse, the contaminant concentrations

increase, putting users a greater risk of suffering health effects. Adverse health effects as a result of exposure to

excessive fluoride concentrations and coliform bacteria are well documented.28

               In 1975 central water softening was discouraged by the Public Health Council because of the

statistical negative association found in 23 communities between the hardness of drinking water and death rate from

Ischemic Heart Disease (I.H.D) over the period 1958 – 1970. Further studies were carried out during the last decade

by a specially assigned interdisciplinary Working Group of the Health Aspects of Central Water Softening. Recent

studies showed that the release of metals (pb and Cu) from household water distribution pipes was positively

correlate with water calcium. Further more a significant negative correlation was found between hardness and pH

for these types of water. The hypothesis that the Ca and Mg deficiency in areas with soft drinking water increases

the risk of I.H.D. death rate was supported by the finding that the food loses more calcium and magnesium when it

is cooked in soft water as compared to cooking in hard water.In contrast with earlier statistical investigations no

significant relations were found over the period 1970 – 1977 between I.H.D. mortality and hardness of drinking

water in 30 municipalities. The provisional conclusion of the Working Group is that other factors than water

hardness overrule to large extent the potential effect on I.H.D. mortality. Central water softening down to 2-3 meq/l

Ca probably will have no observable effect on mortality.29

               A major study on drinking water and heart disease in 1960 by Schroder is given as in his paper

“Relation between mortality from cardiovascular disease and treated water supplies”, the water in 163 largest cities

in United states was analyzed for 21 constituents an correlated to heart disease. He concluded that some factor either

present in hard water, or missing or entering in soft water is associated with higher death rates from degenerative

cardiovascular disease. In 1979 after reviewing fifty studies, Corn Stock concluded that there can be little doubt that

associations of water hardness with cardiovascular mortality are not spurious. He suggested that the reason for this

association is due to a deficiency of an essential element or an excess of a toxic one, or a combination of both is also


               Some studies have shown a weak inverse relationship between water hardness and cardiovascular

disease in men upto a level of 170$nbsp;mg calcium carbonate per liter of water. The World Health Organisation

has reviewed the evidence and concluded that the data were inadequate to allow for a recommended level of

hardness. Recommendations have been made for the maximum and minimum levels of calcium (40-80ppm) and

magnesium (20-30ppm) in drinking water and a total hardness expressed as a sum of the calcium and magnesium

concentrations of 2-4$nbsp; mmol/L. Some studies also correlate domestic hard water usage with increased eczema

in children.31

                 In a study by Harrison, the quantity and effect in cold water and hard water of soaps and detergents

used in dishwashing, laundering and stain removal is examined. He concluded that soap and detergent use goes

down and they become more effective in soft water.32

                 A study by water resource in Tumkur district has conducted and examined the consumption of water

resource with increasing population from 1971 to 1981. By increasing population water consumption is also

increasing people in rural area is becoming more sick. The main cause behind this is the consumption of hard



                 A descriptive study to assess the knowledge regarding hardness of water and its effects among

adults in selected rural areas of Bangalore with a view to prepare a self instructional module.


   1. To assess the knowledge of adults regarding hardness of water and its effect.

   2. To determine the association between knowledge and selected demographic variables.

   3. To prepare a self instructional module regarding hardness of water and its effects.


 1. H1 : There is a significant relationship between knowledge regarding hardness of water and its effects with

    selected demographic variables.


  1. Assess: refers to the process used to identify the level of knowledge of adults regarding hardness of water

      and its effects.

  2. Knowledge: refers to the response given by adults to the structured teaching questionnaire.

  3. Adult: refers to male or female in the age group of 30 – 50 years.

  4. Hardness of water: Hardness of water is the presence of calcium and magnesium ions in water.

  5. Effects: refers to malfunctioning of organs with the consumption of hard water.


  1. It is assumed that adults may have moderate knowledge regarding hardness of water and its effects.

  2. It is assumed that self instructional module will create awareness regarding hardness of water and its effects.


  1. The study is restricted to selected rural areas of Bangalore.

  2. The study is limited to adults in the age group of 30 – 50 years.



                   The source of data will be collected from adults in selected rural areas of Bangalore.


           Research methodology: Non experimental Descriptive Method

           Sampling technique       : Convenient Sampling

           Sample size              : 100 adults

           Population               : Adults selected from rural areas of Bangalore

           Setting                  : Selected rural areas of Bangalore



   This study includes clients,

                  Who are able to read Kannada or English.

                  Male and female adults in the age group of 30 – 50 years.


     This study excludes clients,

              Who are not present at the time of data collection.

              Who are not willing to participate.


                     A structured knowledge questionnaire will be prepared to assess the knowledge of adults

regarding hardness of water and its effects in selected rural areas of Bangalore. A self instructional module will

be prepared on knowledge regarding hardness of water and is effects.

Part-1 : It consist of demographic variables of adults like age, gender, education, occupation, income, lifestyle,

source of water supply, and methods of cooking.

Part-2 : It consist of structured teaching questionnaire regarding hardness of water and its effects.


         Data analysis will be done in terms considering objectives of the study using descriptive and inferential

statistics. Frequency and Percentage Distribution will be done to analyze demographic variables. The Chi-square test

(x) will be done to find out the association between the mean knowledge score with selected demographic variables.



                YES: Only a structured self instructional module and structured knowledge questionnaire will be

used and validated.



   -   Permission consent from the concerned authority will be obtained prior to the study.

   -   Informed consent will be taken from the samples before conducting the study.

   -   Confidentiality and anonymity of the data collected will be maintained.


1. B.T.Basavanthappa, Community Health Nursing, second edition, Jaypee Brothers Medical       Publishers,2005,

   288 – 313

2. Dr.Mrs Kasturi Sunder Rao, An Introduction To Community Health Nursing, revised edition,

   B.I.Publications,2010, 5 – 20

3. John.R.Christopher, Dr.Christopher’s Herbal Legacy Newsletter, Sponsored by The School of Natural Healing

   and Christophers Publications,

4. K.Park, The Textbook Of Preventive and Social Medicine, Eighteenth Edition, M/S Banarsidas Bhanot

   Publishers,2005, 502 – 515

5. Free DIY Home Improvement: Free Aricles on Home Improvement and Remodeling Projects.


6. Vermont Department of Health Agency Of Human Services, Hardness in Drinking Water.


7. Sharon.O.Skipton, Drinking Water: Hard Water (calcium and magnesium)

8.”Healthy Water For Healthy Skin”,—the-har.html

9. Does Hard Water Cause Kidney Stones?, 2009,http://www.water-hardness-and-kidney-stones.htm

10. Shyam Ashtekar, Health and Healing, A manual of primary health care, Orient Longman Publication, 2001,


11. Keshav Swarnkar, Community Health Nursing, Second Edition, N R Brothers Publishers 2008,254-255

12. Charles Weber, The Damaging Effects of Fluoride for Teeth on Thyroid and Brain and a cure, http://Charles-

13. Dr.B Sridhar Rao, Principles of Community Medicine, Fourth Edition, 2005, AITBS Publishers, 224-225

14. Darmaharmony Logo, Hard Water Dermatitis, 2011,


15. Ritu Singh, Study on Quality Of Drinking Water in India, Scholars Research Library, Archives of Applie

   Science Research,2011: 444 – 449

16. Frances A Maurer, Claudia M Smith, Community/ public health nursing practice health for families and

   populations, Third Edition, Elsevier Saunders Publishers, 109

17. Eqinox Lab

18. Peter H Gleick, “Dirty Water: Estimated Death From Water Related Diseases 2000 – 2020, Pacific Institute

   Research Project,

19. African Ministerial Declaration on December 2001

20. Joe Gelt, Consumers Increasingly Use Bottle Water, Home Water Treatment Systems To Avoid Direct Tap

   Water, Water Resource Research Center, The University of Arizona, Arroyo, March 1996, Vol.9,

21. Barbara Strauss, Will King, Arthur Ley and John R Hoey, A prospective study of rural drinking water quality

   acute gastrointestinal illness, Biomed Central, BMC public health 2001,


22. Ferrandiz.J, Abellan JJ,Ocana R, Spatial Analysis of the relationship between mortality from cardiovascular

   and cerebrovascular disease and drinking water hardness, Environ Health Perspect. 2004 jun:1037-44

23. Kaipio j, Nayha s, Valtonen v, Fluoride in drinking water and the geographical variation of coronary heart

   diseases in Finland: Eur j Cardiovasvc Prev Rehabil 2004 Feb, 56 – 62 http://www.cyber-

24. Neckmettin Kocak, Omer Faruk, Water Hardness Level and It’s Health Effects:187 – 192

25. H Tabandeh, G M Thompson, Water Content, Lens Hardness and Cataract Appearance,

26. P.C.Elwood, K.M.Philips, C.K.Toothill, Hardness Of Domestic Water And Blood Lead Levels Human And

   Experimental Toxicology,

27. Robert W Winner, Interactive effects of water hardness and humic acid on the chronic toxicity of cadmium to

   Daphnia pulex,

28. Mark Hill,Ecosystems Sciences Foundation Well Water Quality in San Mighuel De Allende Phase I Results

   And Conclusions,

29. R.L Zielhuis,Water Hardness And Mortality In The Netherlands, The Science Of The Total Environment

   Volume:18 http;//

30. Schroder, Effects of Hard Water, 1960, health/healthc/1-hard-soft-


31. Hard Water, Effects of Hard Water,

32. Harrison, Three hard-vs-soft water studies in 2009, water quality association, 2007,march


33. Water an population dynamics: Case studies and policy implications; Derived from the CGWB document on

   water resource in Tumkur District.


10   REMARKS OF THE GUIDE        Water is the elixir of life. Consuming water

                                 that is pure avoids the chance of ill effects on



     11.1 GUIDE                  Prof. Rachel P George, Principal

                                 HOD Community Health Nursing,

                                 Koshys college of nursing, Bangalore

     11.2 SIGNATURE

     11.3 CO-GUIDE

     11.4 SIGNATURE

     11.5 HEAD OF THE

     DEPARTMENT                  Prof. Rachel P George, Principal

                                 HOD Community Health Nursing,

                                 Koshys College of Nursing, Bangalore

     11.6 SIGNATURE

12   12.1 REMARKS OF THE         Water is the elixir of life. Consuming water

     PRINCIPAL                   that is pure avoids the chance of ill effects on


     12.2 SIGNATURE


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