As we know, most diarrhea is caused by unsafe water, inadequate sanitation and poor hygiene…. in people with immune compromised systems, diarrhea can happen more often and more severely Most people living with HIV get diarrhea…. And diarrhea reduces a body’s ability to absorb life saving medicines and nutrients in food….this causes malnutrition which further exacerbates the effects of HIV Further….care givers have increased work in taking care of someone with diarrhea and the feces in the environment puts others in the home at risk of getting diarrhea as well Finally, people with HIV have greater water needs….to take medicines and for cleaning and washing As transition.. WASH, water, san and hygiene can mean many things to many people.. For this webinar, when referring to WASH, we’re focusing on 3 specific practices… safe drinking water, hand washing and snia. Which have all been shown to make a difference in both general and immuno compromised populations
The most powerful study was conducted by Lule from the US Centers for Disease Control, et al in Uganda in 2005. Intervention was Use of the safe water system that treated water and stored it in a closed container with a tap reduced diarrhea risk by 25% and number of days ill by 33% Presence of latrine was associated with reduced diarrhea risk by 31% and number of days ill by 37% Presence of soap was associated with reduced number of days ill by 42% Similar results in Kenya and Nigeria.
The Hygiene Improvement Project examined national policies and guidelines and explored HIV programs in different countries HIP realized that not much was being done to try to reduce diarrhea in the context of HIV. Further, diarrhea affects more than just the person who is sick…it can affect everyone, and everyone needs to improve hygiene behaviors to prevent diarrhea WASH makes a difference…so the question was HOW can you improve these WASH practices Approach HIP has taken, is to integrate into EXISTING programs HIP started by integrating water, sanitation and hygiene into home based care programs, but many opportunities exist to integrate it further… into other programs such as orphans and vulnerable children and nutrition and HIV
The HIP approach has tried to be holistic….reviewing and improving policies and guidance As well as integrating water, sanitation and hygiene improvements into programming Our approach has been to share the importance about why WASH matters in the HIV context Identify country-specific small doable actions that help people get closer to practicing an ideal practice HIP started a community of practice in different countries to develop tools and share experiences and ideas HIP has developed tools and training that organizations can use to integrate WASH into HIV programs
HIP developed what we call the small doable action approach to help people move toward ideal practices in safe drinking water, Hand washing and sanitation. We know that people need an environment and technologies that makes this possible… So for example, people need access to water to wash their hands and they need containers to store their water safely. But often Getting access to everything needed is impossible, so we need to identify small steps that will move people toward the ideal practice…slowly…. Then outreach or homebased care workers need to identify people’s current practices and congratulate them on the those that are good and health This helps to motivate people to continue to do these practices. Then these outreach workers need to identify practices that can be improved and negotiate options with the person living with HIV or Another household member to try a small actions to improve the practice and so that it is healthier for the person and family members
Here is a sample small doable action for hand washing….. The ideal hand washing would be to wash hands using the proper technique with soap under running water At all the critical times…. But this would be difficult for people who have to go to a central tap down the road and almost impossible for people who have to trek 10 kilometers to fetch water So, what could a person do that would help make him or her healthier, but still be feasible and effective? This small doable action suggests washing hands using ash instead of soap with a tippy tap after using the toilet. The next steps might be to get people to wash their hands at other critical times such as before eating or before and after caring for a sick person
This HIP approach cannot promote the ideal but helps people move toward the ideal in incremental steps… in fact, we have tried to live the small doable action approach in all our work…. HIP and our collaborating partners train outreach workers to do the WASH skills themselves so that they can then teach them to The households they visit. We also teach them skills on negotiating improved practices…. this is asking people to try a new practice and discussing the benefits and problems they might face, and coming up with solutions In the work in Ethiopia and Uganda we have seen some examples of motivation from improved WASH practices…. Reducing the burdens of care and the extra costs - seeing people get better Being proud of cleaner surroundings
The next 10 slides will show the findings of the trial of improved practices (TIPs) research carried out by HIP. TIP is a formative research technique used in behavior change programming. TIP helps to identify WASH small doable actions (SDA) that the HIV program can promote. HIP carried out TIP research in Ethiopia, Uganda, and Tanzania. In Kenya, HIP validated the TIPs from other countries. During the TIPs, the data collectors gathered information of the household WASH current practices, congratulated the client for the good WASH practices already being implemented, negotiated a set of improved WASH actions and followed up over a six week period to get the client’s perspective on what WASH actions are the most feasible. The main findings from Ethiopia, Uganda, and Tanzania are the same. These are some details that are specific to countries. This slide is about making water safer to drink in homes. During the TIPs, we looked at drinking water practices in homes, mainly at points where contamination can occur or can be stopped: Drinking water container Drinking water treatment in homes Drinking water storage –unclean container, not always covered, and reachable by children or animals Unclean cup was often used to draw and serve drinking water Hands of the person drinking water was often in contact with water
These SDA were generated during the TIPs research and were successfully tried by the target audience. Store drinking water in a clean, covered narrow neck container. A narrow neck container prevents people from dipping their hands in the water when drawing drinking water. Treat drinking water at the point of use with an effective water treatment method. The water treatment methods to chose from vary from country to country and depend on what treatment options is available, effective, and is promoted in –country. When serving, pour or use a ladle, don’t hands in the water Keep cup and ladle in a clean place of the ground
Hand washing Current practice needing improvement Wash hand with water and soap if soap is available and if not with water only Dip hands washing from a bowl used by all family members No “systematic” hand washing at critical times
Hand washing SDA Use a water saving device, tippy tap. A tippy tap functions like a tap and allow water to run on the hand to remove the dirt Place the tippy tap and the soap or soap replacement next to the latrine and or next the to bed bound client When soap is not available use soap replacement such as ash, and wash hands properly; this means: wet hands, lather with soap, rub hands together, rinse and air dry.
Feces management Current practices needing improvement are the following: Open defecation still common Inconsistent use of latrine In urban settings, feces from the plastic bags and from the potty is dumped inappropriately Bedbound people soil bed sheet and sometime lay in excrement for hours Animal feces around the house Caregivers don’t always protected their hands where caring for bed bound people
Feces management SDA These SDA refer to the practices or latrine improvements needed to stop the contamination cycle – prevent that feces don’t get in the mouth. Use of latrine for all family members including children > 3 Increase access to latrine and or potty Make adjustments to latrine to help weak people use latrine: such as pole or rope, clear the path Bedridden and children use potty at all times, dispose of the feces from the potty immediately in latrine Wash potty with water and soap Use plastic sheet to protect bed Pen up and or keep animals out of the household compound
Menstrual blood management is a forgotten WASH topic. We noticed that there was a lot of taboos surrounding this topic. Many people, including program partners did not feel very comfortable talking about menstrual blood management when we were designing the TIPs research. Having heard many stories about caregivers (mostly grand-mothers) who contracted HIV when they cared for their children or relatives with HIV, we were convinced that this topic should be included in the TIP research. The objective was to help prevent HIV transmission to caregivers. Menstrual blood management current practice Bed-bound women sometime lack materials to absorb the blood Bed-bound women do not always have access to materials to clean themselves Caregivers touch menstrual blood without protection of hands Knowledge gap The knowledge of risk of HIV transmission associated with the contact with menstrual blood is low
Recommended menstrual blood management SDA Increase access to protection materials: pads, banana fiber Place rag and water next to the bed for the client to clean herself. Soak blood stained materials in a bucket with water and soap until they cane be washed and dispose of properly.
Caregiver should always protect hands with gloves or plastic bags before caring for a bed bound woman with menses Soak blood stained materials in a bucket with water and soap, and wash. Dry material in sun
WASH Integration toolkit The SDAs generated during the TIPs were used to develop the integration toolkit that is comprised of: Competency based training manual Participant’s guide Assessment tool for HBC to use when negotiating improved WASH practices Counseling cards to help communicate with clients during the negotiation, and WASH-HIV integration indicators to help track the progress in the integration of WASH into HIV program
This slide shows a sample outline of training manual content. The purpose of the training was to equip HIV outreach workers with the skills to provide WASH care, to successfully negotiate improved WASH practices at household level, and also to train caregivers on how to provide WASH care to the bed bound people. Sessions are participatory and practical with demonstrations, role play and feedback. This can be adapted and used as modular format or free standing training but can also be integrated into existing HIV training materials Recipe or Cookbook Format
HIV outreach workers were equipped with job aids such as the assessment tool including mostly pictures to help during the negotiation of improved WASH practices in homes. Given the low literacy level of this group, it is easier for them to use pictorials. The job aids serve as reminders and help reinforce the key messages from the training. These job aids are important tools that supervisors should help outreach workers continue to use effectively.
This slide shows another job aid about critical times for hand washing that was developed and distributed to outreach workers.
The job aids also provide solutions for clients’ problems at different stages of disease and mobility in the households. For example here, we see how to help a client use a commode or a potty chair.
Addressing feces management needs of special groups such as weak people and bed bound clients is important. This slide shows ways to help these two groups dispose of their feces safely.
This materials can be downloaded by clicking on the link provided on this slide. You can also send an email to one of the contact listed and we will send you the CD containing this materials. We hope you will find it useful. Feel free to adapt it, copy and paste in your training manual or in any other materials as you see fit. Please let us know how it works.
Meeting the Water, Sanitation and Hygiene Needs of People Living with HIV/AIDS and their Families
April 8, 2010 Welcome to HIP’s Webinar on Presenters: Renuka Bery & Eleonore Seumo, with Julia Rosenbaum and Elizabeth Younger If you have any technical issues during this presentation, contact [email_address] tel. 202-884-8949 Meeting the Water, Sanitation and Hygiene Needs of People Living with HIV/AIDS and their Families
Why WASH Matters <ul><li>Most diarrhea is caused by unsafe water, inadequate sanitation and poor hygiene </li></ul><ul><li>Diarrhea affects 90% of people living with HIV and AIDS, significant morbidity and mortality </li></ul><ul><li>Diarrheal disease reduces antiretroviral absorption </li></ul><ul><li>Diarrhea reduces absorption of nutrients </li></ul><ul><li>Burden on caregivers in clinics and at home </li></ul><ul><li>People with HIV/AIDS have greater water needs </li></ul>
Treating and Safely Storing Drinking Water <ul><li>Treatment and safe storage of drinking water at point of use reduced the risk of diarrhea by 30–40% (USAID 2004); and severity of diarrhea in PLWHA by 35% (Lule et al. 2005) </li></ul>
Hand Washing with Soap <ul><li>Hand washing can reduce the risk of diarrhea by 42-44% (Curtis et al. 2003) </li></ul><ul><li>Presence of soap was associated with reduced number of days of diarrhea (Lule et al. 2005) </li></ul>Hand Washing
Sanitation <ul><li>Presence of latrine was associated with 31% reduced diarrhea and 37% reduced number of days ill (Lule study) </li></ul>
Integrate WASH into HIV programs <ul><li>Home-based Care </li></ul><ul><li>Orphans and Vulnerable Children </li></ul><ul><li>Counseling and Testing </li></ul><ul><li>Prevention of Maternal to Child Transmission </li></ul><ul><li>Nutrition and HIV </li></ul>
Integration Approach <ul><li>Review guidance on WASH within HIV policies and guidelines </li></ul><ul><li>Provide technical assistance on WASH and HIV concepts </li></ul><ul><li>Identify country-specific Small Doable Actions to help people improve WASH practices </li></ul><ul><li>Form a Community of Practice with existing implementing partners to facilitate collaboration </li></ul><ul><li>Provide tools and training that organizations can use to integrate WASH into HIV programs </li></ul>
Small Doable Action Approach <ul><li>Identify feasible incremental steps that move people from a current hygiene practice toward the ideal practice </li></ul><ul><li>Identify existing hygiene and sanitation good practices to be reinforced and congratulate the HIV-positive householder/caregiver for these practices </li></ul><ul><li>Identify practices to be improved and negotiate the options with HIV-positive person/caregiver </li></ul>
Sample Small Doable Action <ul><li>Ideal Hand Washing </li></ul><ul><li>Wash hands with soap using running water at all critical times </li></ul><ul><li>Small Doable Action </li></ul><ul><li>Wash hands with ash </li></ul><ul><li>Use a tippy tap after using the toilet </li></ul>
Integrate WASH into Existing HIV programs <ul><li>Get HIV worker to do and teach the following: </li></ul><ul><li>WASH skills </li></ul><ul><li>Negotiation skills </li></ul><ul><li>Provide motivation </li></ul><ul><ul><li>Reduces burden of care and related costs </li></ul></ul><ul><ul><li>Someone gets better </li></ul></ul><ul><ul><li>Cleaner premises </li></ul></ul>
Drinking Water Treatment Safe Storage & Handling <ul><li>Current Practices Needing Improvement </li></ul><ul><li>Drinking water not treated </li></ul><ul><li>Drinking water often stored in a large mouth unclean container </li></ul><ul><li>Storage container uncovered </li></ul><ul><li>Unclean cup used to collect or serve water </li></ul><ul><li>Hands of the person collecting the water often in contact with water </li></ul>Easily contaminated open water storage
Safe Drinking Water Treatment and Storage <ul><li>Small Doable Actions </li></ul><ul><li>Treat drinking water with an effective treatment method </li></ul><ul><li>Store water in a clean, covered, and narrow-necked container </li></ul><ul><li>When serving, pour or use a ladle, don’t put hands in the water </li></ul><ul><li>Keep serving cup or ladle clean and off the ground </li></ul>Narrow neck with cover
Hand Washing <ul><li>Current Practices Needing Improvement </li></ul><ul><li>Hand washing without soap when soap is not available </li></ul><ul><li>“ Dip” hand washing from communal bowl </li></ul><ul><li>No systematic hand washing after cleaning the potty or after defecation </li></ul><ul><li>No systematic hand washing before eating/cooking, before/after caring for sick or before providing medicine to client </li></ul>“ Dip” hand washing
Hand Washing (continued) <ul><li>Small Doable Actions </li></ul><ul><li>Use tippy tap to conserve water </li></ul><ul><li>Create hand washing station next to client and next to latrine </li></ul><ul><li>When soap is not available, use ash for hand washing—rub hands together, rinse, and air drying. </li></ul>Using a tippy tap
Hand Washing (continued) <ul><li>Small Doable Actions </li></ul><ul><li>Wash hands at key times: </li></ul><ul><li>After defecation or disposing of feces from a potty into latrine </li></ul><ul><li>After cleaning a baby’s bottom </li></ul><ul><li>Before preparing food </li></ul><ul><li>Before eating or helping someone eat or giving medicine </li></ul><ul><li>Before and after caring for a client </li></ul>Using ash for hand washing
Feces Management <ul><li>Defecation in the open </li></ul><ul><li>Difficulty using poorly constructed latrines </li></ul><ul><li>Feces in potty dumped inappropriately </li></ul><ul><li>Plastic bags used for defecation </li></ul><ul><li>Bedbound client soils bed and lays in excrement for many hours </li></ul><ul><li>Bucket potties have feces for hours </li></ul><ul><li>Animal feces found in household compound areas </li></ul><ul><li>Caregivers do not protect hands from client feces </li></ul>
Feces Management (continued) <ul><li>Small Doable Actions </li></ul><ul><li>All family members use latrine and/or potty </li></ul><ul><li>Construct larger latrine and install support poles or stools to assist PLWHA </li></ul><ul><li>Bedridden and children use potty; dispose feces in latrine immediately after defecation </li></ul><ul><li>Wash potty with soap and water </li></ul><ul><li>Use mackintosh/plastic sheeting under sheet to protect bed </li></ul><ul><li>Pen up or keep animals out of household </li></ul>
Current Practice: Menstrual Blood Management <ul><li>Some bed-bound women lack materials to absorb the blood </li></ul><ul><li>Bed-bound women do not always have access to material to clean themselves </li></ul><ul><li>Caregivers touch menstrual blood without protection on their hands </li></ul>
Small Doable Actions: Menstrual Blood <ul><li>Women in periods should use pads, rags or locally available materials (banana fibers) to absorb blood. </li></ul><ul><li>Place water and rags next to the bed for the client to clean blood from her body. </li></ul><ul><li>Put soiled materials in container next to bed until they can be washed or disposed of properly. </li></ul>
Small Doable Actions: Menstrual Blood <ul><li>If caregivers help a women, they should protect hands with gloves/plastic bags when handling menstrual blood and washing rags used to absorb blood. </li></ul><ul><li>Dry cloth in the sun. </li></ul>
Get the HIV/WASH Integration Kit <ul><ul><ul><li>Go to: http://www.hip.watsan.net/page/3442 </li></ul></ul></ul><ul><ul><ul><li>Link to your webpage! </li></ul></ul></ul><ul><li>Contact Information </li></ul><ul><ul><ul><li>Renuka Bery [email_address] </li></ul></ul></ul><ul><ul><ul><li>Julia Rosenbaum [email_address] </li></ul></ul></ul><ul><ul><ul><li>Eleonore Seumo [email_address] </li></ul></ul></ul><ul><ul><ul><li>Elizabeth Younger [email_address] </li></ul></ul></ul>
Question 1 <ul><li>What have you found to be the biggest challenges in implementing wash initiatives and how have you overcome these challenges? </li></ul>
Question 2 <ul><li>I am wondering if HIP includes any policy advocacy components. If so, what have been some of the successes and challenges in this area? </li></ul>
Question 3 <ul><li>Was the menstrual blood management program only targeted at bedridden women or also on regular households? </li></ul>
Question 4 <ul><li>What kind of concrete recommendations can you give to people living with HIV/AIDs in terms of acquiring or building a latrine if they don’t have one? What kind of recommendations do you offer if they don’t have a latrine? Are there organizations in country that can help people acquire or build a latrine? </li></ul>
Question 5 <ul><li>Do all members of the household share the same latrine with an infected member? Or must he or she get their own latrine? </li></ul>
Question 6 <ul><li>How are home based care workers responding to having WASH integrated into their overall scope of responsibilities? </li></ul>