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Baseline Survey Findings Bensa, Ethiopia December 6, 2016 I. PROGRAM SUMMARY In October 2016 Lifewater began a new project in Bensa Woreda, Sidama Zone of the Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia. Lifewater will reach 5 kebeles during the course of the program. Over three years the program will target all households in the 5 kebeles as well as 4 primary schools, for a total of approximately 50,000 people.
Table 1: Target Kebeles, Villages, and Schools
Woreda Target Kebeles Total Sub-‐Villages
Target Schools
Total Population (est.)
Bensa
Keramo 24 1 10,322 Bonbe 45 1 13,960 Segera 24 1 11,803 Shenta Wene 33 1 8,294 Shanta Golba 19 7,345
TOTAL 50,973 Program Goal: To reduce waterborne diseases and improve the health and wellbeing of approximately 50,000 children and families in 5 kebeles (which includes 145 sub-‐villages) and 4 primary schools in Bensa through safe water, sanitation, and hygiene. The project has the following expected outcomes:
1. Increased access to and use of safe water in target communities and primary schools through the provision of 99 new or rehabilitated safe water sources
2. Increased access to and use of improved sanitation facilities in target communities and primary schools through the provision of 8 school VIP latrine blocks (8 doors per block) and intensive sanitation promotion activities at the community, household, and school levels
3. Increase in effective hygiene behaviors in target communities and primary schools through intensive hygiene promotion and education at the community, household, and school levels
4. Increased sustainability of WASH services through capacity building of local and government structures
Lifewater will use its Vision of a Healthy Village strategy to reach vulnerable children and families with improved WASH access and WASH-‐related behavior change. In addition to extensive behavior change programming at multiple levels, Lifewater will complete the following water and sanitation hardware over the course of three years:
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Table 2: Planned Outputs
Outputs Years (fiscal)
Total 1 2 3
Water Points Hand dug wells 6 6 8 20 Protected springs 15 20 30 65
Hand pump repairs 1 2 1 4
Protected spring rehabilitations 3 2 5 10 Latrines
School VIP latrine blocks 2 4 2 8 II. PURPOSE AND METHODS The purpose of this baseline report is to learn about WASH behavior, knowledge, and attitudes/beliefs of the population in the program target areas. This will inform program activities and behavior change messaging. In addition, the baseline will be compared to an endline survey to determine whether the program achieved its objectives. For this analysis, the following data were used:
-‐ Household survey conducted in November 2016: Lifewater field staff surveyed 405 households, a population sample with a 5% margin of error and a 95% confidence interval. The sample size is statistically valid at the level of the total target population, and was not designed to capture generalizable differences between the kebeles. However, comparisons between kebeles are sometimes included in the results and discussion, as they might still be useful for field staff. Data was captured electronically through mobile phones and uploaded into the Akvo Flow system. Sample households were selected from the 5 target kebeles, with the number of samples determined using probability proportional to size. Which communities to sample and how many from each location was determined prior to conducting the survey, and households were selected randomly at the time of the survey. Lifewater HQ analyzed the survey data using Excel and Bensa staff analyzed the focus group discussion (FGD) data. Lifewater HQ drafted the baseline report and received feedback and contextual information from Bensa field staff. The following number of households were sampled in each kebele:
o Bonbe: 114 households o Karamo: 83 households o Segera: 85 households o Shanta Golba: 58 households o Shentawene: 65 households
-‐ Religious institutions survey conducted in November 2016: Bensa staff recorded basic information about all religious institutions they could identify in the target areas. In total, staff identified 89 institutions in the 5 kebeles.
-‐ Focus group discussions conducted in November 2016: Bensa staff completed 10 focus group discussions (FGDs). Staff led 6 FGDs with adults: 1 group of men and 1 of women in Bonbe, Shentawene, and Shanta Golba kebeles. Staff led 4 FGDs with youth: 1 group of male pupils and 1 of female pupils in Karamo and Segera kebeles. Bensa staff analyzed the qualitative data and drafted a report of the discussion themes. Relevant information has been integrated into this baseline report.
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-‐ NOTE: In November 2016 Lifewater staff also completed a survey of all primary schools in the 5 kebeles, for a total of 16 schools. A separate report has been written that details the WASH situation at each of these schools.
III. RESULTS A) Respondent Characteristics and Household Age Structure -‐‑ Respondents: The average age of respondents was 35 years. Of total respondents, 74% were
female. Close to half (48%) of respondents had received no formal education, 37% stopped after attending some primary, and just 15% completed primary or more. Female respondents were less educated than male respondents. Females were almost half as likely to have completed primary or more compared to males (13% vs 23%).
-‐‑ Family structure: The average household size across the 5 kebeles is 5.6 members. Households have an average of 0.6 children under 5 years old, 2.5 youth ages 5-‐17, and 2.6 adults 18 and older. Overall, 11% of the population is under 5 years old, 55% is under 18, and 45% is over 18. See Figure 1 below for a breakdown by age category.
Figure 1-‐ Household Breakdown by Age: Percentage of household
members by age category B) Economic Activity -‐‑ Female economic activity: In 96% of households surveyed, women are engaged in some form of
economic activity, primarily agriculture/crops (89%) and animals/livestock (89%). Small trading is another common economic activity for women (29%).
-‐‑ Household wealth: When asked how their household wealth changed since last year, the majority said it increased (65%), 19% said it decreased, and 16% said it stayed the same. However, 54% said that in the past year they did not have sufficient income for living, and of those who experienced income shortages, the shortages occurred for an average of 4.8 months.
C) Community Resources and Challenges -‐‑ Greatest resources: When asked to name the greatest resources of the community, the most
common responses were livestock/animals (80%), land (80%), and agriculture/crops (77%).
11%
27%
17%
46%
Household Age Structure
Under 5
5-‐12 Years
13-‐17 Years
Over 18
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-‐‑ Greatest problems: When asked about the community’s greatest problems, the most common responses were water quality (64%), roads (55%), water scarcity (48%), and money/poverty (47%). In addition to these, respondents also mentioned electricity (25%), disease (15%), and hunger (13%). See Figure 2 for the percentage of each response.
Figure 2-‐ Greatest Problems in the Community: Percentage who said each response
when asked to name the community’s greatest problems
-‐‑ Most significant change in past year: When asked to name the most significant change in the community during the previous year, the most common response was “nothing” at 32%. The next most frequent responses were improved agricultural yields (16%) and improved infrastructure/roads (10%). Many respondents did not know what the most significant change had been (13%). Only 1% had a negative response (agricultural productivity/income declined). Responses related to improved agricultural yields were spread fairly evenly across all kebeles, while the majority of those who responded with good governance and improved infrastructure/roads live in Shanta Golba and Karamo kebeles. In Segera Kebele, 21% of respondents mentioned new schools/better education as the most significant change. Figure 3 below shows the most common responses by kebele.
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Community's Greatest Problems
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Figure 3-‐ Most Significant Change in the Past Year: Most common responses for the most significant change
in the respondents’ community, shown as a percentage of the total households surveyed in each kebele D) Health and Diarrhea -‐‑ Child health: Respondents reported that the most common illnesses among young children in
their household are cold/flu (79%), diarrhea (46%), respiratory infections/pneumonia (25%), stomach pain (24%), and scabies/skin disease (15%). However, there is noticeable variation between kebeles. Respondents were more likely to report that diarrhea is one of the most common illnesses in Karamo and Shentawene (70% and 72%, respectively) than respondents in Bonbe, Segera, or Shanta Golba (27%, 25%, and 35%, respectively). See Figure 4 for the perceived most common child illnesses by kebele.
Figure 4-‐ Most Common Illnesses in Under 5s (Perceived): Percentage of respondents with children under 5 who listed each illness as one of the most common affecting the children in their household
0%10%20%30%40%50%60%70%80%90%100%
Bonbe Karamo Segera Shanta Golba Shentawene
Percen
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ouseho
lds S
urveyed
Kebeles Surveyed
Most Significant ChangeIncreased trade
Increased education/new schools
Good governance
Improved infrastructure/roads
I don't know
Improved agricultural yields
Nothing
0%
20%
40%
60%
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100%
Cold/Flu Diarrhea Respiratory infection/ Pneumonia
Stomach Pain
Scabies/ Skin
Disease
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Illnesses
Perception of Most Common Illnesses in Under 5s
Bonbe
Karamo
Segera
Shanta Golba
Shentawene
Bensa Total
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-‐‑ In FGDs, participants talked about diarrhea, vomiting, coughing, measles, intestinal parasites, and pneumonia as the dominant illnesses among children under five. There is very little knowledge of how to prevent these diseases, especially diarrhea, with many saying that they do not know what causes diarrhea, only God can prevent it, or simply there is no way to prevent diarrhea.
-‐‑ When asked how the health of their children changed in the past year, 72% overall said it improved, 19% said it declined, and 7% said it stayed the same.
-‐‑ Child diarrhea: Diarrhea prevalence is high. Overall, 17% of children under five had diarrhea during the 7 days prior to the survey. Karamo was the highest at 23%, and Segera and Shanta Golba reported lowest diarrhea prevalence at 12% and 13%, respectively. Bonbe and Shentawene had similar reported diarrhea prevalence (19% in Bonbe compared to 15% in Shentawene). However, in Bonbe, only 27% of respondents named diarrhea as one of the most common diseases affecting children under 5, whereas in Shentawene 72% of respondents named diarrhea as among the most common. See Figure 5 below for a comparison between diarrhea prevalence and perception about how common it is among children, by kebele.
Figure 5-‐ Diarrhea in Households with Children Under 5: Reported prevalence of diarrhea among children under 5 compared to percentage of respondents with children under 5 who believe diarrhea is among the most common illnesses
affecting their children
-‐‑ Careseeking and treatment: When a household had a child with diarrhea in the week prior to the survey, just 32% said the child was given oral rehydration solution (ORS). No one reported using a homemade ORS/sugar-‐salt-‐solution. Overall, 70% gave the child the same or more to drink and eat, which is recommended for home treatment of diarrhea. Of those with diarrhea who are breastfeeding, 78% continued to receive breastmilk during their diarrheal episode.
-‐‑ Diarrhea prevention: Knowledge about ways to prevent diarrhea is mixed. When asked how to prevent diarrhea, 31% overall said they do not know. However, 46% said diarrhea can be prevented by washing hands, 45% said using a latrine, and 26% said drinking safe water. There is significant variation between kebeles in knowledge of the importance of handwashing for diarrhea prevention, with 80% of those in Shentawene knowing that handwashing can prevent diarrhea compared to only 24% of those in Bonbe. FGDs paralleled these findings. In Bonbe, FGD
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Diarrhea Reported Prevalence vs Perception
Diarrhea episode in past 7 days
Diarrhea perceived as very common
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participants said that diarrhea cannot be prevented whereas in Shentawene participants discussed child hygiene as a way to prevent it. See Figure 6 below for a comparison of diarrhea prevention knowledge by kebele.
Figure 6-‐ Knowledge of Ways to Prevent Diarrhea: Percentage of respondents who named
each way diarrhea can be prevented, by kebele
-‐‑ Respondent health: When asked how their own health changed in the past year, 66% said it improved, 25% said it declined, and 8% said it stayed the same. On average, respondents missed 3.7 days of work in the 2 weeks prior to the survey because of illness.
-‐‑ Medical expenses: Only 19% of respondents knew how much their household spent on medical expenses in the 4 weeks prior to the survey. Of those who did know, the average amount spent was 479 ETB ($21.45 USD), with a median amount spent of 150 ETB ($6.72 USD). Out of the 77 respondents who knew how much their household spent, 9 spent more than 1,000 ETB which skewed the mean higher than the median. Comparing Bonbe, which had the lowest knowledge of handwashing to prevent diarrhea, and Shentawene, which had the highest knowledge, households in Bonbe spent an average of 670 ETB ($30 USD) on medical expenses in the previous month whereas households in Shentawene spent less than half that amount, with an average of 287 ETB ($12.86 USD).
E) Water Usage -‐‑ Daily water usage: Daily water usage across the kebeles is extremely low. The average
household uses only 2.3 jerry cans per day, which means 45.7 liters per household. Considering average household size, this is 8.2 liters per person per day. This amount is less than half the 20 liters/person/day minimum for consumption and basic hygiene recommended by WHO1 and far
1 http://www.who.int/water_sanitation_health/emergencies/qa/emergencies_qa5/en/
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Knowledge of Diarrhea Prevention
Bonbe
Karamo
Segera
Shanta Golba
Shentawene
Bensa Total
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below the 25 liters/person/day minimum standard for rural communities set by the Ethiopian government2. See Figure 7 below for a comparison between kebeles and the international and Ethiopian standards.
Figure 7-‐ Daily Water Usage: Comparison of reported daily water usage between surveyed kebeles
and WHO and Ethiopian government standards
-‐‑ Water source for income: Only 1% of respondents said they use their primary water source for income-‐generating activities. Types of activities include vegetable gardens, restaurants/serving tea or coffee, and alcohol brewing.
-‐‑ Water fetching: Adult women are the most likely to fetch water for their families. 68% of respondents said adult women fetch the water for their household, 45% said female children, 25% said male children, and only 2% said adult males. Women and girls are much more likely to fetch water than men and boys.
-‐‑ Yearly water access trends: Overall, trends in water usage vary little between the rainy season and the dry season. Almost half the households use safe sources3 and half use unsafe sources for drinking water. 45% of respondents use a safe source during both dry and rainy seasons and 43% use an unsafe source during both dry and rainy seasons. Of the 43% using an unsafe water source during both dry and rainy seasons, 65% say they use it because they have no other options for water. Overall, only 11% use a mix of safe and unsafe sources.
-‐‑ Use of safe water sources varies between kebeles. 80% and 82% of households in Shentawene get drinking water from a safe source during the dry and rainy seasons, respectively. However, in Segera only 28% and 21% of households rely on safe sources for their drinking water during the dry and rainy seasons, respectively.
-‐‑ Overall, the most common sources of drinking water are protected and unprotected springs. The average total journey for drinking water, including time waiting in line, is approximately 1 hour. The journey times do not vary much between rainy and dry seasons nor between kebeles.
2 Federal Democratic Republic of Ethiopia, “Growth and Transformation Plan II”, May 2016. http://dagethiopia.org/new//docstation/com_content.article/100/gtpii__english_translation__final__june_21_2016.pdf. 3 “Safe sources” in this report includes drilled wells, protected hand dug wells and springs, and bottled water.
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Bonbe Karamo Segera Shanta Golba
Shentawene Bensa Total WHO Standard
Ethiopian Government Standard
Liters per Person pe
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Kebeles Surveyed and Standard Levels
Daily Water Usage
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F) Water Sources -‐‑ Dry season sources: In the dry season, 52% use a safe water source for their drinking water. The
most common source is an unprotected spring, used by 43% of respondents. 39% use a protected spring. Other water sources include bottled water (9%), protected hand dug wells (4%), and surface water (3%). In the dry season, same as in the rainy season, 75% of respondents said their source is public.
-‐‑ Distance and time spent (dry season): The average household travels 718 meters to the dry-‐season water source (one way), spends 11 minutes getting there, and waits for 48 minutes in the queue. This is a total journey time of approximately 1 hours and 10 minutes. Overall, the median wait in the queue is 30 minutes and the median distance is 500 meters.
-‐‑ Rainy season sources: In the rainy season, 48% use a safe water source for their drinking water. As in the dry season, the most common sources in the rainy season are unprotected springs (49%) and protected springs (35%). Just 1 household said they use rainwater.
-‐‑ Distance and time spent (rainy season): The average household travels 713 meters to the rainy season water source (one way), spends 19 minutes getting there, and waits for 24 minutes in the queue. This is a total journey time of just over 1 hour. The median wait in in the queue is 15 minutes and the median distance is 500 meters.
-‐‑ In FGDs, women and men agreed that women and children generally fetch water 2-‐5 times each day. When asked what they would do with their time if the distance to the water point were reduced by half, many said children would be able to attend school punctually, mothers would have more time to care for their children, and the general health and status of their lives would improve.
G) Water Storage and Treatment -‐‑ Treatment frequency: Just 10% of households always treat their drinking water, 1% treat it
sometimes, and 89% never treat their water. The main reason for not treating water is that it is already safe and there is no need (88%). Among those drinking from an unsafe source, during rainy or dry season, 89% never treat their water and 57% said the reason for not treating is that it is already safe. Overall, 32% of those who do not treat their water say they lack the supplies, 14% dislike the taste, and 10% do not know how to treat their water. Shanta Golba and Karamo have the highest percentages of people who always treat their water (37% and 16%, respectively). In the other kebeles, less than 5% of households treat their water.
-‐‑ Treatment methods: Of those who treat their water always or sometimes, the most common water treatment method is filtering (84%). 20% of respondents who treat their water said they strain their water through a cloth. 7% use a chlorine-‐based product such as Pur or WaterGuard. Only 2% boil their water.
-‐‑ Water transportation (observed): Enumerators observed water transportation containers at 96% of households. Containers were likely to have narrow mouths (99%) and be covered (75%) but much less likely to be clean (34%). 33% of all observed were considered “safe,” meaning narrow-‐mouthed, covered, and clean. Whereas three out of the five kebeles had between 31%-‐35% safe water transportation containers, only 8% of containers in Shentawene qualified as safe and in Shanta Golba, 58% of all observed transportation containers were safe.
-‐‑ Water storage (observed): Enumerators observed water storage containers at only 66% of households. Overall, 98% had narrow mouths, 78% were covered, and 44% were clean. 44% of households observed had containers meeting all three criteria for safe water storage, ranging from 0% in Shentawene to 59% in Segera.
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Figure 8-‐ Water Transport and Storage Containers: Observed quality of water containers used for storage and transportation; only water containers that are covered, narrow-‐mouthed, and clean are
considered safe
H) Water Source Management and Functionality -‐‑ Management and performance: Only 23% of respondents said their primary water source is
managed by a committee. Almost half (49%) said their primary water source is privately owned, 21% said their source is public but without a management committee, and 7% were unsure. Of those who said their source has a committee, 67% rated the committee’s performance as good while 13% said it is fair and 16% said it is poor. Another 4% said the committee is not active. The primary reason for a good performance rating was that the source is kept clean (92%). Additional reasons for a good rating included safekeeping of maintenance fees in a bank account (32%), proper collection of the fees (24%), lack of conflict at the source (24%), and community participation (19%).The primary reasons for a poor rating were fees not collected (40%), fees not spent properly (33%), conflict at the source (33%), and the source is not clean (27%).
-‐‑ Payment: Only 4% of households pay for their drinking water. Of those who pay, half pay twice per year. Among the few who pay, the average amount paid annually is 106 ETB ($4.73 USD).
-‐‑ Functionality: 95% of respondents said their primary drinking water source never broke down in the past year. Of those that did break down, the majority (65%) remained broken for less than 1 week.
-‐‑ Repairs: Most respondents (70%) said the community is responsible for repairing the water source when it breaks. Only 15% said repairs are conducted by government technicians, and 15% said that no one repairs the water source when broken.
I) Compound Cleanliness -‐‑ Trash disposal: The most common method of trash disposal is throwing rubbish into the
compost/garden/animals (86%). Others scatter/litter rubbish on the ground (15%). No one reported using a rubbish pit or pail.
-‐‑ Feces and rubbish around compound: During observation, just 15% of surveyed households had no animal or human feces visible around their compound. 73% of surveyed households had animal feces but not human feces on the compound. 6% had human but not animal feces, and 5% had both human and animal feces visible around the compound. The majority of observed
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homes had rubbish visible (86%) and only 6% of homes had neither feces nor rubbish visible in the compound. There was a clear difference in compound cleanliness between those who reported using a latrine and those who reported not having any sanitation facility. Only 8% of See Figure 9 below for more details.
Figure 9-‐ Compound Cleanliness of Latrine-‐users and Non-‐latrine-‐users: Percentage of observed compounds without any visible feces, without any visible rubbish, and without
visible feces and rubbish, comparing respondents who said they use a latrine and respondents who said they do not use any sanitation facility
-‐‑ Child feces: 75% put their child’s feces in the latrine and 17% said all children use the latrine. 9%
said their children practice open defecation. FGDs confirmed that parents put child feces into latrines. However, most adults said they believe child feces are not as dangerous and contain fewer germs than feces from adults.
J) Latrines -‐‑ Latrine use: Overall, 94% of respondents said those in their household defecate in a latrine and
6% said they practice open defecation. Of total people surveyed, 92% said their household always uses a latrine for defecation. When asked who in the household uses the latrine, 100% said women, 99% said men, 86% said children, and just 19% said the elderly.
-‐‑ Ownership: Most households have their own latrine, with only 7% of households using a latrine that is shared with other households. Of those who share, the average number of households using the latrine is 1.8. Among those who do not own a latrine, the main reason is that they do not see a need (52%). Many without latrines also cited concerns over cost (39%) and space/soil (30%) as reasons for not having a latrine. NOTE: This question was only answered by those who said their family doesn’t use a latrine, while it should have also been asked of those who share a latrine/don’t have one of their own. There were just 26 respondents.
-‐‑ Latrine observation: Enumerators observed 120 total latrines. Of all surveyed households, 7% have an improved latrine (defined as a latrine with a slab that adequately covers the pit and is not shared between households). No households have latrines that are “improved with dignity” (defined as an improved latrine that also has whole walls, a whole roof, and a door that offers
16% 15%
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Bensa Total
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complete privacy). Those in Shanta Golba are more likely to have an improved latrine (31% compared to less than 5% in all other kebeles).
-‐‑ All observed latrines were pit latrines and 93% looked like they are used regularly. 98% had slabs made of natural material (1% made of cement) and only 3% had lids for the pit. Most latrines were located 10-‐30 meters from the household (62%), while 21% were less than 10 meters and 18% were more than 30 meters away. Of the latrines observed, the majority had no walls or partial walls (79%), no roof (83%), and no door (87%). Only 23% had slabs without cracks.
-‐‑ Shanta Golba has the highest percentage of households with improved latrines (31%) and also the highest percentages of latrines with solid slabs, solid walls, solid roofs, or solid doors, although no households surveyed had all combined. In Shentawene, no respondents allowed enumerators to observe their latrines.
-‐‑ Latrine maintenance: Latrine maintenance was generally poor, with just 17% of observed latrines being clean, 17% having no smell, and 19% having no flies. 13% were clean with no smell and no flies. Latrines in Shanta Golba were maintained the best of all the kebeles with 24% clean and without flies or smell, followed by Bonbe with 13%. Less than 5% of latrines in Segera and Karamo were clean and without smell or flies.
-‐‑ Difficulty to build: Most people find latrine construction difficult. Only 13% believe building a latrine is very easy and 15% think it is easy. Nearly half believe building a latrine is moderately difficult (45%), and 27% think latrine construction is very difficult. Those who use a latrine think latrines are easier to build than those who don’t use a latrine: 89% of those who don’t use a latrine said it is moderately or very difficult to build a latrine, compared to 71% of latrine users. 13% of latrine users said it is very easy while just 4% of non-‐latrine users said the same.
-‐‑ Satisfaction: When asked how satisfied respondents are with their place of defecation (both latrine users and non-‐latrine users), almost one-‐third said very satisfied (29%) and another third said satisfied (33%), while 25% said unsatisfied and only 13% said very unsatisfied. Rates differed between latrine users and non-‐users. 66% of latrine users were either very satisfied or satisfied whereas no one practicing open defecation was very satisfied and only 8% were satisfied. Figure 10 shows a breakdown of satisfaction by latrine use.
Figure 10-‐ Defecation Location Satisfaction: Respondent satisfaction with their place of defecation, comparing respondents who said they use a latrine and respondents
who said they do not use any sanitation facility
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-‐‑ Latrine benefits: The most commonly perceived benefits of using a latrine are health/disease (92%) and cleanliness (91%). Others appreciate the privacy (17%), comfort (13%), and safety (10%) of latrines.
-‐‑ Disadvantages of defecation location: 32% of respondents said there are no disadvantages to their defecation location. This was higher for latrine users at 34% compared to non-‐latrine users at 15%. Overall, the greatest disadvantages of their place of defecation for both those who do and do not use latrines are smell (62%) and flies (60%).
K) Hygiene -‐‑ Handwashing station observation: Enumerators were only permitted to observe 6 handwashing
stations, reflecting just 1% of surveyed households. 44% of respondents said they did not wish for enumerators to observe where they usually wash their hands and 55% said they did not have such a place. Of the 6 observed, none had soap or ash and all of them re-‐used water. 3 of the 6 were located near the latrine and 2 were inside/near the kitchen.
-‐‑ Handwashing practice (reported): Despite observing very few handwashing stations, 100% of respondents said they washed their hands in the 24 hours prior to the survey. Overall, 53% of respondents said they washed their hands with soap or ash and water in the past 24 hours.
-‐‑ Times for handwashing (practice): Overall, 19% said they used soap/ash and washed at the 2 most critical times for disease prevention (after defecation and before eating) during the past 24 hours. 32% of those surveyed said they washed their hands at the 2 most critical times (with or without soap). This was twice as high in Shanta Golba and Karamo than Segera (41% and 40% compared to 20%). Among caregivers, 13% said they washed their hands after handling child feces/changing the baby. Only 5% of caregivers washed before feeding or breastfeeding their child. Among food preparers, 85% said they washed before cooking or handling food, although less than half of those (45%) said they used soap or ash. The most common times for handwashing were before eating (90%), before food preparation (81%), upon waking up (50%), after defecation (35%), and after touching dirty things (30%).
Figure 11-‐ When People Wash Their Hands: Times that respondents reported washing their hands in
the 24-‐hour period prior to the survey, by kebele
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-‐‑ Knowledge of times for handwashing: Respondents were only slightly more likely to know the
important times to wash hands than they were to actually practice them. When asked to list the important times for handwashing, 92% said before eating and 37% said after defecation. Only 14% know that after handling child feces and 4% that before feeding a child are important times to practice handwashing, although 85% know that they should wash hands before cooking or preparing food.
-‐‑ Handwashing benefits and difficulties: The perceived benefits of handwashing include that it removes dirt/makes hands clean (89%), removes germs (62%), prevents disease/diarrhea (44%), and promotes general health/wellbeing (35%). Those who say they use soap are slightly more likely to say that handwashing removes germs (63% among soap-‐users and 60% among non-‐soap users) and prevents diarrhea/disease (47% among soap-‐users and 42% among non-‐soap users). Overall knowledge of the relationship between handwashing and disease prevention is high: 93% of respondents mentioned some form of health benefit to handwashing.4 When asked what makes handwashing difficult, two-‐thirds said there were no difficulties (66%). One-‐third said the cost is difficult (33%) and 11% said they lack water. Only 4% said that there is no need or that it is not important to wash their hands.
-‐‑ Hygiene education: Education on hygiene and sanitation is low. Just 37% have ever received hygiene/sanitation education and 34% said there is currently someone teaching hygiene/sanitation in their community. The proportion of respondents who said they have previously received hygiene/sanitation education was more than three times greater in Shanta Golba (66%) than in Segera (19%). Overall, among those who said there is education happening currently, most said it is from health extension workers (80%) followed by the government (48%), religious leaders (24%), and the village chief (14%).
-‐‑ Bathing: The majority of respondents bathe once per week (69%), 17% bathe more than once per week, and no one bathes daily. 11% of respondents bathe less than once per week. The most common source of water for bathing is surface water at 58%, and the next most common sources are unprotected springs and protected springs at 16% and 15%, respectively.
-‐‑ Menstrual hygiene management: Most female FGD participants said it is difficult to manage their menstruation because of challenges in obtaining necessary materials as well as the negative stigma and shame associated with menstruation. Women said they are less likely to participate in social events and market places because of the gossip and because “people view it as a taboo or incorrect thing.” Some women have received education about menstruation from teachers or health extension workers, while many others have not received any education on menstruation.
-‐‑ Dish rack: Enumerators observed that 20% of surveyed households had a dish drying rack. Of the observed drying racks, 69% were raised off the ground to protect from animals. When asked where the household members dry dishes, 43% said on a table and 38% said on the ground.
L) Animals on Compound -‐‑ Sleeping location: Most households (81%) have animals living on their compound. Of those who
do, 12% said the animals sleep outside, 63% said the animals sleep inside the house and in the same room with people, and 25% sleep inside but with separation between humans and some or all of the animals. Those in Karamo, Shanta Golba, and Shentawene are much more likely to sleep with their animals than those in Bonbe and Segera. This could be because the types of
4 Health-‐related responses included “removes germs,” “prevents diarrhea/disease,” and “health/well-‐being”
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animals people own varies between kebeles, with some animals being more likely to sleep inside the house than other types of animals.
Figure 12-‐ Animals Sleeping Location: Percent of respondents with animals living on their compound
disaggregated by where those animals sleep
M) Religious/Spiritual -‐‑ Religious institution presence: Protestant churches are the most common religious institutions
across the surveyed kebeles. 99% of respondents said there is a Protestant church in their community, and only 2 respondents (1%) said there is an Ethiopian Orthodox Church. Just 2 respondents (1%) said there is a mosque. 90% of those who said there is a Protestant church said the church cares very much for the community and 89% said the church is very active in the community. 7% of those with Protestant churches said the church cares somewhat for the community, and 8% said the Protestant church is somewhat active. Only 2% said the Protestant church does not care at all about the community and 2% said the church is not active at all. According to the Religious Institutions survey, the five kebeles surveyed have a total of 85 Protestant churches and 4 mosques.
-‐‑ Impact on health: Unseen forces are believed to have a greater impact on people’s health than humans. Most respondents believe God has an impact on their family’s health and an additional 13% believe spirits impact health. Less than 2% believe that ancestors or witch doctors/ traditional healers have an impact on their family’s health. Only 24% responded that they themselves had an impact on their family’s health and 11% said that neighbors have an impact.
-‐‑ Cares about future: When asked who cares about their future, almost all respondents (99%) said God cares about their future. The next most common responses were one’s family (13%) and the government (12%). Only 3% said that the church cares about their future.
-‐‑ God’s care: The results were virtually unanimous that God cares deeply about the respondents and their families. 99% said that God cares about them very much, 100% said that He cares very much for their health/wellbeing, and 100% said God cares very much for their children.
0%10%20%30%40%50%60%70%80%90%
100%
Percen
tage of R
espo
nden
ts with
Animals o
n Co
mpo
und
Kebeles Surveyed
Where Do Animals Sleep?All inside main house together with peopleSome inside main house in different section/roomAll inside main house in different section/roomOutside main house
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N) Next Generation -‐‑ Life for the next generation: Respondents were overwhelmingly hopeful about the future. 100%
said life will be better for the next generation. When asked why, the most common responses had to do with learning/education (52%) and God’s help (37%). A few people mentioned the economy (4%). Figure 13 below shows the translated responses, with the size of the response reflecting its frequency.
Figure 13-‐ Why Life Will Improve for the Next Generation: Most common responses about why life will be
better for the next generation. The size of the response is proportional to its frequency IV. DISCUSSION Water Half the population drinks water from unsafe sources, and most of those using unsafe sources do not treat their water before drinking. Most respondents recognize water as one of the greatest problems in their community, and people are not choosing to drink from unsafe sources out of preference but out of necessity. Women spend much of their day fetching water – spending an average of 2-‐5 hours per day journeying to and from the water source. The impacts of the water situation in Bensa are far-‐reaching. Mothers are not able to care for their children as they would like, children are missing time in school, and families do not have sufficient water for their daily needs. Even water from safe sources is often becoming contaminated through transportation and storage in dirty containers. Whereas almost all water containers are narrow-‐mouthed and approximately three quarters have covers, far fewer are clean. Water treatment also requires improvement, as 89% of people never treat their water before consumption.
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The most common sources of drinking water are unprotected springs, and very few people are paying for their water. Overall, only 2% of water sources were broken for more than a week in the previous year. Because people have had such reliable access to water without paying, it may be challenging to encourage regularly saving of funds. There also seems to be some incidences of improper use of funds which may further discourage people from contributing to operation and maintenance. NOTE: The survey was not designed to be statistically valid at the kebele level, only at the level of the entire sample. Therefore, the survey is limited in its ability to identify generalizable differences between kebeles. However, there are interesting trends which may support understanding and implementation in the region, and they are described below. Bonbe Of all the kebeles surveyed, Bonbe has the highest change in water sources between dry and rainy seasons. Whereas most respondents use the same water sources during both seasons, one-‐tenth of respondents in Bonbe switch from a safe water source during dry season to an unsafe one during rainy season. Of those who switch from a protected to an unprotected spring during the rainy season, one-‐third said they choose the unprotected spring because it is quick/convenient and another third said because of its good taste. Bonbe has relatively average rates of water treatment, safe water storage, and daily water usage. Karamo In general, Karamo aligns with the overall averages for all water sections. Segera The lowest safe water access of all surveyed kebeles is in Segera, where only around a quarter of respondents use safe water sources. People travel an average distance to the water source that is higher than any other kebele, and twice as high as the average in Shanta Golba. Perhaps due to this distance, the queue time is very short. In addition to having very low use of safe water sources, every household surveyed in Segera said they never treat their water to make it safe. Over half in Segera said that they consider their water to already be safe, and half said they don’t have the necessary supplies to treat their water. Interestingly, water transportation containers had average cleanliness and water storage containers were the cleanest of all surveyed kebeles. Shanta Golba In contrast to Segera, Shanta Golba has both higher use of safe water sources as well as more common water treatment application. More than two-‐thirds get their drinking water from a safe source and more than one-‐third always treat their water before drinking. As well as having the highest percentage of respondents who treat their water, Shanta Golba has the highest percentage of safe water transportation containers. Almost all of the observed containers were covered and more than half were clean. Shentawene Shentawene has the highest percentage of respondents using safe water sources during both seasons, however almost none of the water containers observed in Shentawene were clean and very few respondents treat their water. Therefore, it is likely that people are drinking contaminated water even if it is coming from a safe source. Daily water use is lowest in Shentawene of all surveyed kebeles; people are using just one-‐quarter of the minimum amount recommended by WHO and just a fifth of the Ethiopian government standard.
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Sanitation Nearly all respondents said they use latrines and FGDs participants said they value latrines. FGD participants discussed that latrines keep the area clean and are important for good health, and that they hoped to be able to improve the superstructures of their latrines. While knowledge of the connection between health and latrines is clear (over 90% said that one benefit of a latrine is health/reduced disease), specific understanding about the connection between open defecation and diarrheal disease may not be as well understood. One-‐third of respondents were unaware of how to prevent diarrhea and less than half identified latrine-‐use as a way to prevent diarrhea. Though many report using a latrine for defecation, very few of these latrines are up to the necessary quality and safety standards. Attention needs to be given to improve the dignity and privacy conditions. Superstructures are generally missing or in very poor quality. Few latrines are clean and without smell or flies, and most people complained of the smell and flies in their latrines. If people are motivated, latrine cleanliness can be significantly improved with pit covers and regular maintenance. Latrine users are moderately satisfied with their latrines, but few noted that comfort and privacy are benefits of a latrine. Improving the quality of latrines may increase satisfaction and help people see the benefits of privacy. Shanta Golba has by far the most improved latrines (30% in Shanta Golba compared to less than 5% in all other kebeles). It would be beneficial to look into the successes in Shanta Golba and try to scale those up in the other kebeles. It is common practice to litter/scatter rubbish on the ground, feed it to the animals, or throw it into the garden. Many compounds are not kept clean-‐ during observation, 94% of households had rubbish and/or feces visible on their compound and no respondent had a rubbish pit. Few had dish drying racks. Each of these corresponds with a Healthy Home behavior (i.e., compound clean of feces and rubbish and drying racks outside to sanitize dishes in the sun away from animals), and has a direct impact on the health of the home. Hygiene Handwashing is a very serious issue in all kebeles. Though everyone said they washed their hands that day, only half said they used soap and few washed hands after defecation. Very few people know that it is important to wash after contact with feces (whether one’s own feces or a child’s) and almost no one knows the importance of washing hands before feeding a child. No households had an appropriate handwashing device and none had soap or ash for handwashing on their compound. Menstrual hygiene is a problem for many women and girls. FGD participants said they have difficulty obtaining cloth pads, they are embarrassed and taunted during menstruation, and they exclude themselves from activities while they are menstruating. Some of the younger women are learning menstrual hygiene management, most older women did not receive menstruation education. This points to the importance of the WASH in Schools program, including building latrine blocks with private changing rooms and supplies for girls. Health Diarrhea incidence in children is concerning. Nearly one-‐fifth of children under 5 years old had diarrhea during the 7 days prior to the survey. Diarrhea was named by many as a common illness among children under 5. Surprisingly, actual diarrhea prevalence did not always correspond with perception of how common it is among children in the different kebeles. Improved WASH can be expected to reduce all of
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the most common child diseases reported by households (cold/flu, diarrhea, respiratory infections/pneumonia,5 stomach pain, skin disease/scabies, worms, and eye infections/trachoma). Most people do not withhold food or water from children with diarrhea, but only one-‐third give the child ORS (increasing fluid intake and using ORS are critical behaviors in treating diarrhea). In FGDs, most participants said that children with diarrhea should be taken to a health facility. Medical expenses were quite high, with the average household spending 479 ETB ($21.45 USD) in the past 4 weeks. Decrease in WASH-‐related illnesses should also decrease the amount of money spent on illness by households. Knowledge is very low about the causes of diarrhea and ways it can be prevented, including significant misunderstandings. One-‐third of survey respondents do not know any ways to prevent diarrhea. Nearly half know that latrines can prevent diarrhea and almost half know that handwashing also prevents diarrhea, but only one-‐quarter know that drinking safe water is also important for diarrhea prevention.
5 Rabie T, Curtis V (2006) Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11(3): 258-‐67
