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Kap report endline september 2012



Knowledge Attitudes and Practices End-Line Assessment on water, Sanitation and Hygiene, Lolkuach, Gambella, Ethiopia

Knowledge Attitudes and Practices End-Line Assessment on water, Sanitation and Hygiene, Lolkuach, Gambella, Ethiopia



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Kap report endline september 2012 Kap report endline september 2012 Document Transcript

  • KNOWLEDGE ATTITUDES AND PRACTICES (KAP) END-LINE ASSESSMENT On Water, Sanitation and Hygiene LOLKUACH Village, IDPs of Akobo September-2012 DRC-Gambella WASH Team Conducted in the frame of an ECHO funded project “Improving access to short-term food security, safe drinking water, hygiene and basic household items in Ethiopia” Wanthowa Worda, Gambella, Ethiopia September 30, 2012 i
  • TABLE OF CONTENTS1 INTRODUCTION 12 SUMMARY OF FINDINGS 23 METHODOLOGY 33.1 Objectives of the Survey 34 FINDINGS 44.1 General Background Information 45 WATER RELATED INFORMATION 55.1 Water Sources 55.2 Water collection and storage 95.3 Household Water Treatment 116 HEALTH AND HYGIENE 126.1 Diseases 126.2 Washing Hands and Good Hygienic Practices 157 SANITATION 187.1 Defecation 187.2 Waste and Waste Management 208 CONCLUSION 239 RECOMMENDATIONS 2410 REFERENCES 25 i
  • 1 IntroductionThe 2012 report states that as of end of 2010: Over 780 million people are still without access toimproved sources of drinking water and 2.5 billion lack improved sanitation. If current trends continue,these numbers will remain unacceptably high in 2015: 605 million people will be without an improveddrinking water source and 2.4 billion people will lack access to improved sanitation facilities. Anestimated 801,000 children younger than 5 years of age perish from diarrhea each year, mostly indeveloping countries. This amounts to 11% of the 7.6 million deaths of children under the age of fiveand means that about 2,200 children are dying every day as a result of diarrheal diseases. Unsafedrinking water, inadequate availability of water for hygiene, and lack of access to sanitation togethercontribute to about 88% of deaths from diarrheal diseases (UNICEF, WHO, 2012: 2; Center of DiseaseControl and Prevention, 2012).As to Andrea Naylor: although worldwide there have been thousands of projects to address water andsanitation issues as they relate to public health with continued improvements since the 1980’s, researchhas shown that due to lack of evaluation surveys on the effectiveness and success of theseinterventions, many are not sustainable . To this end, the essence of conducting end-line survey is verycritical to gauge the effectiveness and success of the interventions of DRC-Gambella.The Gambella Region has an approximately population of 332,600 people, with 49,457 living in Akoboand Wantawo Woredas. These populations are subjected to water shortage and floods. Moreover thepopulation is prevalently pastoralist and follows seasonal migration patterns for cattle grazing andprotection of livestock from drought and floods. The perennial attacks by the Murle tribe, coupled withintra-clan conflicts among the Nuer tribes of Ethiopia and South Sudan, aggravates a situation of chronicdisplacement, making populations of bordering areas, especially Akobo, susceptible of massive andprolonged internal displacements.Conflicts, drought and floods are the key challenges to the populations in Akobo and in Wantawo. Theconsequent perennial movement makes the community vulnerable to food insecurity, disease andwater shortage. It is in view of this that Danish Refugee Council seeks to address in the short term thebasic needs of these populations by providing access to clean drinking water, and tools to improvehygiene and to build the capacity of the community to respond to these challenges. 1
  • From the period of July 2011 to June 2012, DRC implemented a Water, Sanitation and Hygiene project,funded by ECHO, with the goal of rehabilitating 7 hand pumps (and subsequently chlorinating thewater), distributing NFI kits, hygiene kits, and implementing hygiene promotions.DRC decided to conduct two in-depth KAP surveys (as a baseline and endline) to evaluate the impactbrought by the implementation of the project in the targeted area. The baseline survey was conductedin the month of May 2012 and the end line survey was conducted in the second week of September2012. In the period between the two surveys, a number of activities covering water, sanitation andhygiene were implemented in the frame of the project.2 Summary of FindingsProject outputs and behaviour and knowledge change (as indicated by the pre and post implementationKAP surveys) indicate the following key findings:o Seven hand pumps were rehabilitated/ disinfectedo Hygiene promotion targets were surpassed. (planned: 5,490 beneficiaries; 10,950 reached)o Hygiene kit distributions were surpassed (planned: 2,250 beneficiaries; 8,870 reached)o NFI kit distributions were surpassed (planned 6,300 beneficiaries; 7,470 reached)o The number of respondents who use hand pumps as source of water increased from 4% to 75%o Knowledge and practice of feasible water purification practices such as boiling, filtration or adding tablet/sachet has been greatly improvedo Instance of diarrhoea has decreased from 60% to 24% of respondents stating that they had had diarrhea in during the 3 weeks prior to the surveyo Knowledge that rain water is a safe drinking water source has improved from 24% to 62% of respondents, however, the use of rain water remains limited.o Knowledge of the causes of unsafe drinking water (including germs, visible particles and bad taste) increased from 40% to 81%.o The practice of open defecation has reduced from 100% to 15% of respondents.o Hand washing at critical times has increased from 34% to 85% of respondents. 2
  • o Appropriate waste disposal mechanisms improved from 39.2% in baseline to 75% of respondents..o Although there has been an improvement in the knowledge of respiratory and eye infection transmission/protection, there is still room for improvement3 MethodologyA cross sectional, qualitative study was conducted through house to house interviews, taking 150respondents randomly as study subjects. The sample represents nearly 10% of the total targeted 1household in Lolkuach village (1,500 household). The questionnaire (See Annex I) was employed tocollect data on general background information, knowledge, attitude and practices of the IDPs ofLolkuach village. However the results can also be considered pertinent for the host communities ifconsidering the cultural and environmental homogeneity. Verbal consent from the respondents wasobtained after explaining the purpose of the study. Data was collected from 13 to 14 September 2012.The data from the questionnaires was entered into SPSS software (version 13) by the principalinvestigators for further analysis.Data reliability was assured using different techniques such as:  Properly designed questionnaires were prepared and pretested.  Data collectors were hired locally and tested during the training on the contents of the questionnaire. Constant supervision was done by DRC WASH Team Leader, and problems encountered at the time of data collection were reported immediately and appropriate actions taken.3.1 Objectives of the Survey  To identify gaps in knowledge regarding health and hygiene practices and existing practices leading to negative impact on health.  To describe the socio demographic, cultural information of respondents and villages.  To find out the information on incidence of communicable disease due to unhygienic practice.1 It is estimated, on the base of IOM Akobo IDPs database, that the number of households currently living in Lolkuach is 1500 and average family size is 5. 3
  •  To assess the effectiveness and impact of the DRC water, sanitation and hygiene promotion activities.4 Findings4.1 General Background InformationThe beneficiaries of the programme, and KAP survey respondents are all part of the displaced Nuer-Gajok population from Akobo Woreda now living in Wantawo. Among the KAP survey respondents, themajority (about 65 %) were female, whereas 35% were male. Females were particularly targeted for theKAP survey, as they were the primary recipients/participants in the DRC project, and are traditionallyresponsible for child care and household WASH issues.This survey was conducted near the end of the rainy season, in Lolkuach IDP settlement. Respondentsreported moving between the river banks temporary camps and dry land permanent villages accordingto seasonal variations. During the dry season, the majority of the respondents live in Dimbierow village(79%), and Nyawich village (17%), while only 4 % of the respondents indicated that they live in Lolkuachvillage throughout all the year. However there are frequent movements among the settlementsthroughout all the year.Most of the respondents (86.2%) indicated that they arrived at Lolkuach between February and June2009 following a recurrence of conflict with Lou Nuer in Akobo woreda. Minority of the respondentsarrived during the same period of 2008 (12.8%) or 2010 (1 %). Most of the respondents therefore havebeen displaced since 2009.When respondents were asked if they plan to return to their villages of origin, a pronounced number(55%) indicated that they don’t have any plans to return due to security problems (expressed as ‘war’,‘conflict’, ‘insecurity’). The remaining 45% of the respondents indicated that they plan to return back inthe future if the security situation is restored and the construction of the road from Mathar to Akobo isfinalized. In this regard, as it can be observed from the baseline survey, no significant difference noted inthe end line survey. However looking in detail at the positive answers (from the 45% of respondents),21% expressed a plan to go back within six months and the remaining 34% indicated a time longer thansix months. Moreover even the respondents who indicated that they have a plan to return back to 4
  • Kebele of origin also mentioned their fear about the security situation (expressed as ‘if peace comeback’, ‘if cattle raiding ends’, if the construction of the road to Akobo is completed and similar).5 Water Related Information5.1 Water SourcesBefore the project interventions, the baseline data indicated that almost 100% of the respondents wereaccessing unsafe drinking water from the river, which is contaminated from the presence of livestockand open defecation. At the end of the project implementation, the hand pumpmaintenance/rehabilitation/water chlorination, coupled with pure sachet distributions, bucketdistributions, and hygiene promotions resulted in a significant positive change.As you can observe from the Figure 1, the majority of the respondents are now using water from newlymaintained/rehabilitated hand pumps. Due to seasonal movement however, the proportion ofrespondents using hand pumps during the dry season reduces, as many of the beneficiariesmove to areas without hand pumps. The following graph outlines both the shift in hand pumpuse (pre and post intervention), and also the relation of this use in terms of seasons. There arestill not sufficient hand pumps in Lolkuach area to support the population however, which explainswhy 100% of the respondents are not using these protected sources. Considering that the 7500inhabitants of Lolkuach, Thore and Lolmokoney have only 7 hand-pumps (hand dug wells), this isinsufficient as per SPHERE standards)2 , highlighting the need to construct new hand pumps.2 Considering the maximum number of users for 1 hand pump should be 500, at least 15 hand pumps would be needed in Lolkuach 5
  • Seasonal Use of Protected Water Sources - Pre and Post Intervention 100 90 % of Respondents 80 70 60 50 40 30 20 10 0 Dry Season Rainy Season Baseline Seasons Endline Figure 1: Shift in Use of Protected Water Sources (KAP baseline an d end-line)Seven hand pumps in Lolkuach and surrounding villages were disinfected and beneficiaries receivedpure sachet as well bucket and filter.From the findings, the graph below states that it is only 27% of the respondents indicated that the mainproblems with their water source are water is dirty and it tastes bad. Whereas 40.7% of the respondentsalso signified that the water source is far. Problems Related to Water Supply 100 90 80 % Respondents 70 60 50 40 30 20 10 0 Dirty Water Bad Taste Irregular FlowSource is Dried Distance to No problems Up Source Baseline Water Source Issues Endline Figure 2: Main problems related to water supply. 6
  • Consequently 63% of the respondents consider the water they are using is safe for drinking, and 33%consider it is unsafe instead (Figure 3). This represents a reduction in the proportion of respondentswho stated that they were using unsafe water from 77% in the baseline to 33% in the end-line survey.Of these 33% of respondents who noted that they were drinking unsafe water, 8% of the respondentswere using hand dug wells (Which were rehabilitated by DRC) as source of water for drinking.Figure 3: consideration of water safety Figure 4: reasons why 33% declared water is unsafeIn relation to the safety of water, the reason why 33% of respondents declared that they are usingunsafe water is mainly because the water contains germs, is not filtered and not cleaned. This showsthat their understanding about the causes of unsafe water has improved since the baseline (Figure 4).When it comes to use of rainwater as source, though improvement is registered, much needs to be doneto bring about significant change. Considering the shortage of safe water sources in the area observedby DRC, and the abundant rain-fall in Gambella region3, reasons for not using the rainwater (which isalmost distilled4) were assessed more closely. Although the number of respondents who believe that3 The annual rain falls in Gambella region ranges between 800 and 1200mm, but about 85% of rains are concentrated betweenMay-October (Woube, 1999).4 In this regards, Dev Sehgal, indicated that rainwater harvesting is an easy method to collect drinking water, and the quality ofthe water is almost distilled. First when the water touches the catchment surface it usually gets contaminated (Dev Sehgal, 2005). 7
  • rainwater is unsafe has reduced from 76% to 38% of respondents, more can be done to raise awarenesson this water collection method. Of the 38% of respondents who would not collect rain water given thechoice, the principal reasons were given as follows: Figure 5: Investigation about unused rain waterWhen questioned on their knowledge of safe drinking water and water pollution causes, respondentswere given the option of providing more than one answer.The number of respondents who indicated that drinking water shouldn’t have germs, visible particlesand/or bad taste, increased from 40% at the baseline to 81.3% at the end-line.The respondents who indicated that the proximity of a latrine to water sources can cause watercontamination increased from 7.2% in the baseline to 15% in the end-line survey. In this regards, waterquality and health council indicated that especially the proximity of latrine to water sources can causeRemoving the first harvested water, so-called first flush, can prevent this. When the rain starts to fall the first water cleans thecatchment surface and fills up the first flush diverter, by the time it is full a ball closes the opening and leads the water to themain tank. The downside of rainwater harvesting is that it requires double storage, as it is hard to purify water at the same speedas it rains (Gould, J. & Nissen-Petersen, E., 2005). 8
  • 5contamination . The majority of the respondents (85%) also indicated that garbage disposal or animalsfeces containers near a water source, or unprotected source can cause water contamination (Figure7). Knowledge of Causes of Water Source Pollution 100 90 80 70 % Respondents 60 50 40 30 20 10 0 Defecation Garbage Dirty Nearby Nearby Container Baseline Causes of Pollution Endline Figure 7: Knowledge of Water Source PollutantsAlthough only a small proportion of respondents acknowledge that water can be contaminated throughthe ground from a latrine constructed too close to a water source, 95% of respondents are now awarethat defecation near a water source is a pollutant, resulting in a change of behavior in which opendefecation has reduced from 100% in the baseline to 15% in the end-line survey.5.2 Water collection and storageFrom the Figure 8, it can be observed that nearly 50% of respondents less than 50 minutes to fetchwater during dry seasons6, meaning that SPHERE standards for these respondents are met for water-source distance because of the rehabilitations of the hand pump in the vicinity of the village. Concerningrainy season, it can be observed that respondents spend more time getting water. As it is observed,respondents need to travel some distance to fetch water and during the dry season respondents alsomove to river banks. Hence, this can make the access to hand pump difficult. So besides constructing5 The causes of water pollution vary and may be both natural and anthropogenic. However, the most common causes ofdomestic water pollutions includes : garbage disposal and defecation near water sources, animals feces, sharing the samesources with animals, use of dirty or open water container can affect the safety of our water .Use (Water Quality and HealthCouncils, 2010; CAWST, 2009; Laurent, P., 2005).6 According to SPHERE key indicators, the maximum distance from any household to the nearest water point is 500 metres 9
  • new hand pumps, encouraging the community for rain water catchment strategy is very essential athousehold at household level. 70 60 50 40 30 Dry Season Rainy Season 20 10 0 0-50 50-100 100-250 More Min Min than 250 Figure 8: Average time spent to collect waterGiven that water collection requires women and girls to walk distances to find water sources, there maybe heightened protection issues for these family members, although protection was not assessed in theKAP.Question posed to respondents on what devices that they are using to store and collect water indicatedthat 55% of the respondents are using plastic jerry cans to collect water and 34% of the respondents useplastic bucket for water collection. For storing water, nearly 33% of the respondents use traditional claypot and plastic jerry cans; the rest 36% of the respondents indicated plastic jerry cans or buckets withlid.DRC distributed NFI (Contains 2 Jerry cans each 20 litters among others) and Hygiene kits (Contains 2Buckets each 10 litters among other) to 302 and 283 households respectively living in Lolkuach areas. Tothis end, most of the respondents own more than one container. But still those who didn’t receive waterstorage and collection device also were among the respondents who took part in the survey, we can 10
  • observe that 70% of respondents meet the minimum SPHERE7 requirement for water collectioncontainer, and 74% meet the requirement8 for water storage. Whereas in the baseline, it wasnoted that only 50% of the respondents met the requirement for water storage and collectiondevices.5.3 Household Water TreatmentThe knowledge of practical purification methods like boiling, filtration or adding tablet/sachet wasassessed. As it can be observed from Figure 12, there is great leap in knowledge of the basic methods ofhousehold water treatment. For instance, use of purifying sachet/tablet increased from 8% at baselineto 85% at the end-line survey. The findings also suggested that the majority of the respondents (morethan 75%) know the use of feasible practices like boiling, filtration or adding tablets/sachet for watertreatments9.This figure was only 25% in the baseline survey. After the baseline survey, it is worth tonote that DRC-Gambella has been distributing purifying sachet and providing demonstrations for thosevillages with no access to hand pumps.7 According to SPHERE key indicator: Each household has at least two clean water collecting containers of 10-20 litres, plusenough clean water storage containers to ensure there is always water in the household. The amount of storage capacityrequired depends on the size of the household and the consistency of water availability e.g. approximately 4 litres per personwould be appropriate for situations where there is a constant daily supply8 Requirement for storage is calculated according to certain specificities, but considering the minimum of4lt/person/day, for an average household of 5, should be at least 20 lt.9 Different researchers suggested some feasible practices like boiling, filtration or adding Figuret/sachet and chlorination forwater treatment (CAWST, 2009; Davis & Lambert, 2002). 11
  • Knowledge of Household Water Treatment 140 120 100 % Respondents 80 60 40 20 0 special Boiling Use of Cleaning Filtering Covering sunlight container sachet container with cloth Baseline Endline Figure 12: Knowledge of household water treatment methods6 Health and Hygiene6.1 DiseasesRespondents were asked about the diseases their family experienced during the three weeks before theinterview. The number of respondents who caught diarrhea in the three weeks prior to the interviewreduced from 60% in the baseline to 27.3% in the end-line survey. Hence, you can see from the end-linesurvey that hygiene conditions and practices are improving.When it comes to the causes of diarrhoea, more than 85% of the respondents referenced unsafedrinking water, children feces, germs/bacteria, open defecation, poor hygienic practices and flies ascauses of diarrhea (Figure 16), indicating that the hygiene promotion has resulted in an increase inknowledge. 12
  • Figure 16: Knowledge about diarrhea transmissionInterviewees were asked to indicate in a multiple choice question, which action to be taken to protecttheir families from the different diseases that they suffered from.The respondents who indicated that they can be protected from malaria by sleeping under mosquito netincreased from 40% to 75%. Keeping the environment clean and good hygienic practices also attributedas a method of prevention of malaria by many respondents (Figure 14). 13
  • Knowldge of Malaria prevetion measure 120 100 % Respondents 80 60 40 20 0 Keeping Safe water Good Use Wash cloth Wash hand environment hygienic mosquitonet Clean practice Baseline Endline Figure 14: knowledge of malaria prevention measuresWhen it comes to skin diseases, most of the respondents indicated that good hygienic practice as way ofprevention of skin diseases (Figure 15). 14
  • Figure 15: Knowledge of skin diseases prevention measur esNearly 51.2% of the respondents indicated that good personal hygiene, keeping the environment clean,use of safe water for drinking, washing hands, washing clothes and hanging them in the sun can protecttheir families from respiratory and eye problems.The above results indicate that the knowledge of the people has improved with regards to respiratoryillness and eye infection transmission and protection, however there is still room for improvement.6.2 Washing Hands and Good Hygienic PracticesGeneral question about hygiene and more specific ones about hand washing were posed.Keeping food away from flies, bathing regularly, keeping compounds clean, protecting food and washinghands are considered as good hygienic practices by the majority of the respondents in the end-linesurvey. This means that the figure increased from nearly 51% at the baseline to nearly 85% in the end-line. 15
  • Figure 18: Knowledge about keeping good hygieneLikewise, when respondents specifically asked if they wash their hands, 89% of the interviewees gaveaffirmative answer in the end-line Survey.People who wash hands reported to be doing it in order to eliminate bad smell and prevent diseases.Similarly more details of the hand washing practice can be seen from Figure 20, and it can be concludedthat more than three fourth of the population who wash their hands, are doing it at the appropriatetimes. 16
  • Figure 20: Frequency of hand washing practiceWhile the vast majority of the respondents (95%) stated they would like to bathe once a day, when itcomes to practice, 29% of respondents expressed they have problems in taking bath regularly mainlybecause of lack of container and soap (Figure 21).Hygiene practices were also considered to be a major issue by nearly 40.6% of the respondents, theserespondents indicated that poor practices are due to both a lack of access to hygiene items, and a poorattitude brought on by a lack of knowledge. So the majority of the respondents signified that thedistributed hygiene kits solved some of their problems and they were adhering to good hygienicpractices. 17
  • 7 Sanitation7.1 DefecationBefore the DRC intervention, the majority of the adults practiced open defecation. Because changinghabits is not easy, the baseline assessment was designed to understand the risk practices that weremost widespread and identify those that could be changed. From the point of view of controllingdiarrhoea, the priorities for hygiene behavioral change included hand washing at critical times and safestool disposal. To this end, the efforts of the organization brought significant behavioral change. Fromthe end-line survey it is noted that 85% of the respondents use traditional latrines, which is up from 0%.Similarly, when asked to indicate the best option for defecation, 85% indicated the latrine. On the otherhand, privacy, water pollution, presence of bad smell and flies, as well as spread of disease was reportedas the main problem related to open defecation practices (Figure 23). Respondents were also askedabout post defecation cleansing habits and mostly indicated pieces of paper. Figure 23: Problems related to defecation practice 18
  • Considering the majority of respondents indicated that a latrine is the best option for defecation, andthat the main issue with defecation is privacy, disease, water pollution, smell and environmentalpollution, it was observed that the traditional latrine which is constructed by the participation of thecommunities has been welcomed and used by the community.In the baseline survey it was found out that inadequate sanitary conditions and poor hygiene practicesplayed major roles in the increased burden of communicable disease within the village. Similarly, thebaseline information stated that beneficiaries had problems with access to safe water and sanitationfacilities. To this end, DCR Gambella set a strategy to solve the problems through communityparticipation.DRC- Gambella inculcates the basic principles andapproaches of CLTS (Community Lead TotalSanitation) into the newly designed PHAST(Participatory hygiene and Sanitation Transformation)training. As both approaches opt for communities’participations and empowerment and focus onigniting a change in sanitation and hygiene behaviour,a PHAST training manual that encompasses bothPHAST methodology and catalysts for change insanitation behaviour was prepared and distributed.After community based health promotions work, andcommunity conversation establishments at eachvillage, the accessibility to sanitation facilities and sanitation practices improved. 1446 households whocompleted hand washing points and traditional pit latrine (See the figure on the right side) wereawarded NFI to recognize their efforts of behavioral changes.Hand washing after stool contact and safe disposal of stool have been priorities in hygiene andsanitation promotion interventions in Wanthowa Woreda. By understanding that for the quickest andwidest adoption of good hygienic practices it is often more cost-effective to rely on social ambitionsrather than health arguments to encourage change, DRC linked hygiene promotion works with socialand cultural values, norms as well as NFI distributions, such that all hygiene promotions were linked withcultural problems of Nuer society and social values. As a result good improvements in both hand 19
  • washing and safe stool disposal were registered. This can be confirmed by looking at the end line KAPsurvey results.7.2 Waste and Waste ManagementThe majority of disease measures are related to environmental conditions: appropriate shelter, cleanwater, good sanitation, and vector control, personal protection such as (insecticide-treated nets,personal hygiene and health promotion). Appropriate waste disposal mechanism is vital to avoidenvironmental pollution and breading place for vectors and pathogens. In this regards, the majority ofthe respondents (75%) indicated that they are now burning the household solid wastes on timely bases(Figure 24). The number of respondents who had been disposing solid wastes in open space and riversignificantly decreased after the interventions. Figure 24: waste disposal practice 20
  • The problems concerning waste were indicated in flies, bad smell, breeding place for mosquitoes.Majority of the respondents understood that appropriate solid waste disposal plays a vital role inminimizing the breading of vectors and other pathogens (Figure 25). Figure 25: Problems related to waste disposalThe majority of respondents indicated that the practice used to dispose household waste is burning.Improvement in waste disposal and keep the villages clean is observed by DRC field staffs. Similarly theviews of the majority of the respondents on the attributes of clean and health village is improved. It isnoted that availability of safe water, cleanness of the village and availability of latrine considered bymore than three fourth of the respondents as the attributes of clean and health village in the end-linesurvey. But those we stated the same were nearly 50% in the baseline survey. 21
  • Similarly, the benefits of keeping a village were mainly identified as decrease of diseases occurrence,improved beauty of village, minimized presence of mosquitoes and flies by more than three fourth ofthe respondents in the end-line where as this nearly 53% in the baseline.From end-line survey, it can be inferred that majority of respondents indicated that important publichealth factors such as availability of safe water and latrines, absence of stagnant water and mosquitoesamong the attributes of an healthy village. They also noted that this has great impact in reduction ofinfection disease prevalence. Hence, it can be concluded that the understanding of the majority of therespondents on disease transmission, transmission routes and its preventions tremendously improvedafter the interventions. 22
  • 8 ConclusionDiarrhoea causes dehydration and kills approximately 2.2 million people, mostly children, every year.Children are more likely than adults to die from diarrhea because they become dehydrated morequickly. In the past 10 years, diarrhea has killed more children than all of the people lost to armedconflict since World War II. Its occurrence is closely related to the opportunities that poor people(especially poor mothers) have to improve domestic hygiene10. Diarrhoea does not only cause diseaseand early death in children, but also affects children’s nutritional status, stunting children’s physical andintellectual growth over time. Skin and eye infections are especially common in arid areas. Bothdiarrhoea and other infectious diseases have health as well as socio-economic consequences. Washingmore often can greatly reduce their spread11 . Similarly, the training manual of Amhara region indicatedthat improved hygiene, particularly hand washing at critical times can reduce diarrhea by one third andreduce malnutrition12. Soiled hands are an important source of transmitting diarrhoeas.Recent research also suggests that hand washing is an important preventive measure in the incidence ofacute respiratory infections, one of the top killer of children under five.13This KAP survey was conducted in order to compare its results with the results of the baseline survey, toidentify whether the hygiene promotion activities conducted in the frame of the ECHO funded projecthad been effective.The baseline and end-line survey results revealed that positive results have been achieved in the overallhygiene situation. In the baseline survey the situation was poor i.e. lack of safe water, poor sanitationfacilities, poor hygiene practice etc. At the end of the project, an improvement was noted in the overallhygiene and sanitation behaviour. Though improvements were noticed after the implementation ofproject, it should not be forgotten that it takes time to consolidate behaviour changes, so more followup is necessary for further improvement.10 (Curtis et al., 2000).11 Brian Appleton and Christine van Wijk (IRC), 2003.12 Amhara Regional State Health Bureau, 2011; Isabel Carter, 200513 See for instance the study of Ryan et al. published in 2001 23
  • 9 RECOMMENDATIONSAlthough the WASH project can been seen as a success, the team noted some recommendations forfuture interventions.  Construct 15 shell wells in Lolkuach village so that inhabitants meet SPHERE standards  Assess whether it is possible to dig wells in the locations where people move to during the dry season  Introduce rain water harvesting techniques, which are easy sources of potable water and would reduce the distance travelled to access water, thus improving the protection status of the women and girls that are responsible for this task.  Follow up on well water quality in rehabilitated wells  Although respondents recognized that animal feces can contaminate water, only 15% in the end-line noted that the proximity of a latrine to a water source can contaminate drinking water. This could be stressed and improved in future hygiene promotion activities. 24
  • 10 References 1. Amhara Regional State Health Bureau (2011). Training Manual on Hygiene and Sanitation Promotion and Community Mobilization for Volunteer Community Health Promoters (VCHP)/ Draft for Review. Online Available at: http://pdf.usaid.gov/pdf_docs/PNADP828.pdf 2. Andrea Naylor. Development and Implementation of Sanitation Survey Using a Knowledge Attitudes Practices (KAP) Model. University of South Florida (Tampa): CGN6933 “Sustainable Development Engineering: Water, Sanitation, Indoor Air, Health” and PHC6301 “Water Pollution and Treatment”. 3. Brian Appleton and Christine van Wijk (IRC) (2003). Hygiene Promotion Thematic Overview Paper. IRC International Water and Sanitation Centre 4. Boot, Marieke T. and Cairncross, Sandy (1993). Actions speak: The study of hygiene behaviour in water and sanitation project. The Hague: IRC International Water and Sanitation Centre. 5. CAWST (Centre for Affordable Water and Sanitation Technology) (2009) Household water treatment and safe storage factsheet: natural coagulants. Online Available at: http://cawst.org/en/resources/pubs/file/38-hwts-fact-sheets-academic-english 6. Davis, J. and Lambert, R (2002) Engineering in emergencies – A practical guide for relief, workers 2nd edition, Rugby: Practical actions publishing 7. Dev Sehgal, J. (2005) A guide to rainwater harvesting in Malaysia. Online Available at: http://www.wasrag.org/downloads/technology/A%20Guide%20to%20Rainwater%20Ha rvesting%20in%20Malaysia.pdf 8. Esrey, S.A. (1994). Complementary strategies for decreasing diarrhea morbidity and mortality: water and sanitation. Paper presented at the Pan American Health Organization, March 2-3. 9. Gould, J. & Nissen-Petersen, E. (2005) Rainwater catchment systems for domestic supply. Rugby: ITDG publishing. 25
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