Increased proportion of schools with < 100 children per latrine stand with hand washing facilities, ..... If the yield of the spring is high, and the number of users is few, then it is possible to ..... Orchard or fuel wood grove is developed over time.
Water Supply, Sanitation and Hygiene for Health Extension Workers A Short Term Training Manual
September 2014 Addis Ababa, Ethiopia
Water Supply, Sanitation and Hygiene for Health Extension Workers
A Short Term Training Manual of Ethiopian Institute of Water Resources, Addis Ababa University Prepared by: Akeza Awealom (B.Sc., M.Sc.) Taffere Addis (B.Sc., M.Sc., M.Sc.)
September 2014 Addis Ababa, Ethiopia
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Disclaimer: The author‟s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. iii | P a g e
Acknowledgments Ethiopian Institute of Water Resources (EIWR), Addis Ababa University wishes to acknowledge the technical support and local data provided by partner universities i.e. Arba Minch University, Hawassa University, Mekelle University and Bahir Dar University and Regional Health Bureaus during the preparation of this Short Term Training Manual. This manual is prepared based on the feedback and review of the partner university undergraduate students of 2014 summer outreach water supply, sanitation and hygiene (WASH) baseline survey and acknowledged as their findings were valuable for shaping the training manual. EIWR of Addis Ababa University highly acknowledges the United States Agency for International Development (USAID) and Higher Education for Development (HED) for funding this Water Supply, Sanitation and Hygiene (WASH) training manual preparation.
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Abbreviations/Acronyms AAU: Addis Ababa University EIWR: Ethiopian Institute of Water Resources USAID: United States Agency for International Development HED: Higher Education for Development HEW: Health Extension Workers WASH: Water, Sanitation and Hygiene MDG: Millennium Development Goals MoU: Memorandum of Understanding ODF: Open Defecation Free OWNP: One WASH National Program WIF: WASH Implementation Framework UNICEF: United Nation Children's' Fund CLTS: Community Led Total Sanitation GDP: Gross Domestic Product WHO: World Health Organization JMP: Joint Monitoring Program VIP: Ventilated Improved Pit latrine GTP: Growth and Transformation Plan PHAST: Participatory Hygiene and Sanitation Transformation
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Table of Contents Contents
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List of Tables and Figures.......................................................................................................................... viii Training Schedule ......................................................................................................................................... 1 UNIT ONE: INTRODUCTION TO WATER SUPPLY, SANITATION AND HYGIENE ........................ 2 1.1 Introduction to Water Supply, Sanitation and Hygiene (WASH) ........................................................ 3 1.2 Ethiopian WASH Strategy .................................................................................................................... 3 1.3 Status of WASH in Ethiopia ................................................................................................................. 4 1.4 Definition of Terms ............................................................................................................................. 6 UNIT TWO: WATER SUPPLY .................................................................................................................. 9 2.1. Introduction ..................................................................................................................................... 10 2.1.1 Water Associated Disease .......................................................................................................... 10 2.1.2 Water supply standards .............................................................................................................. 12 2.1.3 Sources of Drinking Water ............................................................................................................. 15 2.2 Water Supply Current Status (WHO & UNICEF, 2014) ...................................................................... 16 2.4. Household level water treatment .................................................................................................... 27 2.5. Household water storage ................................................................................................................. 37 UNIT THREE: SANITATION ................................................................................................................... 39 3.1. Introduction to sanitation ................................................................................................................ 40 3.2. Sanitation and disease transmission................................................................................................ 41 3.3. Sanitation Facility ............................................................................................................................. 42 3.3.1. Cat/Scrap Latrine ...................................................................................................................... 43 3.3.2. Arborloo latrine ......................................................................................................................... 44 3.3.3.. Simple pit latrine ...................................................................................................................... 46 3.3.4. Borehole latrine ......................................................................................................................... 50 vi | P a g e
3.3.5. Ventilated pit latrine.................................................................................................................. 50 3.3.6. Compost latrine ......................................................................................................................... 52 3.3.7. Overhung latrine ....................................................................................................................... 54 3.3.8. Bucket latrine ............................................................................................................................ 54 3.4. The effect of poor sanitation ........................................................................................................... 57 UNIT FOUR: HYGIENE PROMOTION AND COMMUNITY EMPOWERMENT ............................... 59 4.1 Personal Hygiene .............................................................................................................................. 60 4.1.1. Body hygiene ............................................................................................................................ 60 4.1.2. Hand hygiene ............................................................................................................................ 61 4.1.3 Teeth Hygiene ............................................................................................................................ 63 4.1.4. Eye hygiene ............................................................................................................................... 65 4.1.5. Hair hygiene .............................................................................................................................. 65 Figure 21: How to keep our hair clean ................................................................................................ 66 4.1.6. Foot hygiene.............................................................................................................................. 66 4.1.7. Clothes hygiene ......................................................................................................................... 67 4.1.8. Menstrual Hygiene .................................................................................................................... 67 4.2 Hygiene Promotion ........................................................................................................................... 69 4.3 Community Participation and Empowerment .................................................................................. 73 UNIT FIVE: REGIONAL CONTEXT PROBLEMS AND RECOMMENDED SOLUTIONS .................................. 81 Major Challenges In 2006 E.C(2013/14 G.C) at National Level............................................................... 81 Tigray Region ..................................................................................................................................... 82 Amhara Region ................................................................................................................................... 84 Oromia Region .................................................................................................................................... 86 Southern Nation, Nationalities and Peoples Region ........................................................................... 88 References ................................................................................................................................................... 91 vii | P a g e
List of Tables and Figures List of Tables Table 1. A recommended basic water requirement for human domestic needs............................13 Table 2. Access to Improved Drinking Water Sources............................................................16 Table 3. Checklist for open dug well water (rope and bucket system) sanitary inspection...........23 Table 4. Checklist for covered dug well with hand-pump sanitary inspection............................24 Table 5. Checklist for protected spring source inspection........................................................25 Table 6.Checklist for rainwater collection and storage inspection............................................26 Table 7. Behaviors to be recommended in hygiene education..................................................71 Table 8. Stages in the community participation process.........................................................74 Table 9. Characteristics of effective health education.............................................................76 Table 10. Potential human resources for hygiene education in the community............................78 Table 11. Five leading causes of under 5 years morbidity in Sidam Zone, Southern Peoples Nations and Nationalities Region, 2014................................................................................88 Table 12: Top ten leading cases of above 5 years Morbidity in Sidama Zone, Southern Peoples Nations and Nationalities Region, 2014................................................................................88 Table 13. Top 10 causes of morbidity in Arba Minch Zuria woreda, (in all age groups at Inpatient Department & Out Patient Department level), 2006 E.C...........................................89
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List of Figures Figure 1: Solar disinfection......................................................................................................28 Figure 2: Homemade sand filter...........................................................................................31 Figure 3: Candle filter........................................................................................................32 Figure 4: Cloth filtration.....................................................................................................33 Figure 5: "F" diagram and barriers.......................................................................................42 Figure 6: People practicing open defecation.........................................................................43 Figure 7: Cat/Scrap Latrine....................................................................................................................44 Figure 8: Arborloo latrine...................................................................................................45 Figure 9: Simple Pit Latrine..............................................................................................47 Figure 10: Non functional pit latrines...................................................................................49 Figure 11: Borehole latrine................................................................................................50 Figure 12: VIP latrine.........................................................................................................51 Figure 13: Single and double pit..........................................................................................53 Figure 14: Overhung latrine...............................................................................................54 Figure 15: Bucket Latrine.....................................................................................................55 Figure 16: How to keep personal hygiene............................................................................61 Figure 17: How to wash hands thoroughly............................................................................62 Figure 18: How to keep our hands clean...............................................................................63 Figure 19: How to keep our teeth clean..................................................................................64 Figure 20: What to do to have good smell.............................................................................64 Figure 21: How to keep our hair clean.................................................................................66
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Ethiopian Institute of Water Resources (EIWR) Narrative The mission of Ethiopian Institute of Water Resources is to enhance capacity of higher education institutions in Ethiopia in their educational programs, research and community engagement that will result in improved and sustainable water resources use and management to ensure food security, promote clean energy production, improve human and environmental health, advance educational opportunities and promote sustainable socioeconomic development without altering the environment. The Institute is running Water and Health program that integrate education, research and community outreach program. WaSH is one component of its outreach aimed in creation of awareness for experts and community in regard with water and health issues. The training manual is developed mainly for Health Extension Agents working mainly in rural community. Regional context issues are included in consultation with partner universities and Regional Health Bureaus. The undergraduate WASH baseline surveys conducted across the regions were the main inputs for the contextualized manual preparation. We hope the training manual will also used as reference handbook for health extension workers in WASH implementation.
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Training Schedule Day One.
Chapter One
Chapter Two
Day Two.
Chapter Three
Day Three.
Chapter Four
Day Four.
Field visit for sanitary survey
Day Five.
Presentation of sanitary survey report and integrating with regional context problems identified in Chapter Five
UNIT ONE: INTRODUCTION TO WATER SUPPLY, SANITATION AND HYGIENE
Unit description This chapter deals with the general concepts of Water supply, Sanitation and Hygiene for its role in health promotion and disease prevention.
Unit Objectives At the end of this session the trainees will be able to:
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Define different terms related to WaSH
Explain Ethiopia's WaSH strategy and its status
1.1 Introduction to Water Supply, Sanitation and Hygiene (WASH) The aim of any WASH programme is to promote good personal and environmental hygiene in order to protect health. An effective WASH programme relies on an exchange of information between the agency and the affected population in order to identify key hygiene problems and culturally appropriate solutions. Ensuring the optimal use of all water supply and sanitation facilities and practicing safe hygiene will result in the greatest impact on public health. WASH needs of the affected population are met and users are involved in the design, management and maintenance of the facilities where appropriate. Identify key risks of public health importance in consultation with the population. Provide and address the public health needs of the population according to their priority needs Systematically seek feedback on the design and acceptability of both facilities and promotional methods from all different user groups on all WASH programme activities
1.2 Ethiopian WASH Strategy The Federal Government of Ethiopia is committed to fulfilling the Millennium Development Goal (MDG) of reducing by 50 per cent the proportion of the population without access to water and sanitation by the year 2015 - thereby improving the overall health and socio-economic condition and quality of life of the population, especially children and women. Consequently, Ethiopia has adopted ambitious water, sanitation and hygiene targets through its “Universal Access Plan”, which seeks to reach 98.5 per cent and 100 per cent access to safe water and sanitation respectively by 2015. The national hand washing strategy objectives includes:
Increased proportion of household utilization of improved sanitation facilities from an estimated 31 per cent to 84 per cent,
Increased proportion of schools with < 100 children per latrine stand with hand washing facilities,
Increased proportion of households practicing hand washing with soap (or a substitute) at critical times from an estimated 7 per cent to 77 per cent,
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Increased proportion of Open Defecation Free (ODF) Kebeles from an estimated 15 per cent to 80 per cent and
Increase the proportion of households practicing home water treatment and safe storage from an estimated 8 per cent to 77 per cent.
To enhance multi-sectoral coordination, the Ministries of Education, Health and Water resources signed a Memorandum of Understanding (MOU) in 2006 to enhance multi-sectoral coordination. The purpose of this MOU is to get the main partners of WASH sector involved in joint planning, implementation and monitoring of water supply, sanitation and hygiene education (WASH) in communities, schools and health institutions. The One WASH National Program (OWNP) was launched on September 13/2013 to operationalizes the Memorandum of Understanding (MoU) and the WASH Implementation Framework (WIF) signed by the Ministries of Water and Energy, Health, Education and Finance and Economic Development in November 2012 and March 2013, respectively.
OWNP has four components of:
Rural WASH
Pastoral WASH
Urban WASH
Institutional WASH
1.3 Status of WASH in Ethiopia Since 1990, improved sanitation coverage increased from 2% to 21% in 2011 and 24% of the population use facilities that do not yet meet basic hygiene standards. Open defecation rates decreased from 92% in 1990 to 37% in 2012 (i.e. 55% per cent reduction in open defecation practice). Progress has been equitable across all states though the population in the poorest quintile benefitted least from improvements in sanitation. Between 1990 and 2011, the number of people using an improved sanitation facility increased from 1.1 million to 17.5 million people. 10.4 million people rely on shared sanitation facilities, 38.1 million people still practice open defecation (36.9 million of Ethiopia‟s 38.1 million open defecators live in rural areas). 4|Page
Ethiopia is among the top five countries with the fastest, reduction in open defecation rates and as of June 2013, around 2,042,735 people were living in 7,032 Open Defecation Free (ODF) village communities as a direct result of UNICEF support for Community Led Total Sanitation (CLTS). Around 2.5% of the country‟s population are now living in ODF certified communities.
Diarrhea is the leading cause of under-5 mortality in Ethiopia, causing 23% of all under-5 deaths (73,341 children per year).
An estimated 64,540 children could be saved every year by
improving Water, Sanitation and Hygiene in the country. Around 44% of under-5 children in Ethiopia are stunted, which can be strongly linked to the childhood incidence of diarrhoea and other mechanisms such as environmental enteropathy (disease of intestinal tract). The need for water and sanitation is fundamental to all citizens, and increased coverage of these essential services will significantly contribute to population welfare as well as the wealth and stability of Ethiopia. Economic studies conducted in Africa have shown that impacts resulting from poor sanitation and hygiene cost the economies between 0.9% and 2.4% of annual Gross Domestic Product (GDP). This translates approximately US$ 10 per capita per year. These figures reflect the a) adverse health effects associated with poor sanitation and water supply, b) costs of treating these health problems, c) loss of productivity that results when individuals are sick and others have to care for them, and d) time spent to access services. These estimates do not include the costs associated with environmental impacts (e.g. polluted water) and the adverse impacts on tourism and business. An important contributor to these costs is child mortality: the World Health Organization (WHO) estimates that diarrheal diseases caused the deaths of around 85,000 children under five years old in Ethiopia in 2008. The indirect effects of malnutrition - to which poor water and sanitation contribute 50% according to WHO report- cost a further 3,800 lives. Emerging evidence suggests that if a country like Ethiopia has a reputation for poor environment, polluted water and an unhealthy workforce, it can affect its ability to earn foreign currencies, and hence hinder economic growth. Furthermore, as the effects of climate change are felt with increased predictions of extremes such as flooding and droughts it will become even more important to invest in resilient water supply and sanitation systems. 5|Page
Even if Ethiopia meets the MDG target in both rural and urban areas, 49% of the rural population and 39% of the urban population would remain without access to improved sanitation; and 50% of the rural population would still be using unimproved sources of drinking water. The government of Ethiopia has introduced since the end of 2004 Health extension agents to deal with sixteen health packages. Seven of them are Environmental Health packages where Water, Sanitation and Hygiene (WaSH) is part of it.
1.4 Definition of Terms Basic sanitation: As defined by the United Nations Millennium Project Task Force on Water and Sanitation, basic sanitation is the “lowest-cost option for securing sustainable access to safe, hygienic and convenient facilities and services for excreta and sullage disposal that provide privacy and dignity while at the same time ensuring a clean and healthful living environment both at home and in the neighborhood of users.” Ecological Sanitation: Sanitation whose design builds on the concept of protecting ecosystems, and which treats excreta as a valuable resource to be recycled. Hygiene: refers to practices associated with ensuring good health and cleanliness. This includes Hand washing with soap and water at critical times most notably after defecation or before contact with food and strict observation of the safe drinking water chain. Health promotion aims at preventing disease and promoting positive health by enabling people to have increased control over their physical, mental and social well being. Hygiene promotion is a part of health promotion which focuses on the prevention of water and sanitation related diseases. Hygiene promotion seeks to understand and build upon existing knowledge, practices and resources in the community. The goal of hygiene promotion is for people to develop safe hygiene practices. From a participatory viewpoint, hygiene promotion focuses on people identifying their own hygiene practices Hygiene Promotion: A planned approach to preventing diarrheal diseases through the widespread adoption of safe hygiene practice. it begins with and is built on what local people
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know, do and want and behaviors and developing ways to improve them and reduce their risk to disease. Hygiene education: the teaching of hygiene information. For example, hygiene education can include information about how disease is spread and how people can stop this spread. This message-based approach to disease prevention might be appropriate in certain circumstances e.g. when people want this type of information, but this type of approach does not generally lead to positive behavior change. Successful hygiene promotion programmes use broader types of approach including social marketing, participatory learning and peer influence. Improved hygiene and sanitation: As defined by the 2005 National Hygiene and Sanitation Strategy, improved hygiene and sanitation is the process where people demand, develop and sustain a hygienic and healthy environment for themselves by erecting barriers to prevent the transmission of diseases, primarily from faecal contamination. Environmental Sanitation: a range of intervention designed to improve the management of excreta, sullage, drainage and solid waste. Household water treatment: any activity to improve water quality undertaken at the household level. Sanitation: World Health Organization (WHO) defines sanitation as group of methods to collect human excreta and urine as well as community waste waters in a hygienic way, where human and community health is not altered. Sanitation methods aim to decrease spreading of diseases by adequate waste water, excreta and other waste treatment, proper handling of water and food and by restricting the occurrence of causes of diseases. On-site sanitation: system of sanitation where the means of collection, storage and treatment( where this exists) are contained within the plot occupied by dwelling and its immediate surroundings. Off-site sanitation: system of sanitation where excreta are removed from the plot occupied by the dwelling and its immediate surroundings.
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Palatable water: water that is pleasant to drink because its taste is good but it may not be safe to drink. Pit Latrine: Latrine with pit for collection and decomposition of excreta and from which liquid infiltrates in to the surrounding soil Potable water: safe for drinking, free from pathogens and toxic chemicals which are introduced to the water through feces, dirty containers, etc. Pour-flush latrine: latrine that depends for its operation of small quantities of water, poured from a container by hand, to flush away faeces from the point of defecation. Raw water: water that has not been purified. Safe water storage: the use of clean containers with covers and good hygiene behaviours that prevent contamination during water collection, transport, and storage in the home. Ventilated Improved Pit Latrine: pit latrine with a screened vent pipe and darkened interior to the superstructure which is designed to keep flies out and minimize smell.
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UNIT TWO: WATER SUPPLY
Learning Objectives: At the end of this chapter the trainees will try to understand the basic principles of water supply and their public health importance Unit Objectives: Learner are expected to
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Define some terms related to water supply
List what water associated diseases are and their control mechanisms
Know water supply standards
Identify sources of drinking water supply
Assess water contamination and suggest possible control measures
Undertake sanitary survey
Know possible household based water treatment options
2.1. Introduction Water is essential for life, health and human dignity. It has always played a prominent role in human civilization. In most cases, the main health problems are caused by poor hygiene due to insufficient water and due to the consumption of contaminated water. Having ready access to safe water, therefore, has always been important.
2.1.1 Water Associated Disease Water-associated disease can be defined as a disease related with water (supply) and sanitation. There are four water-associated diseases categories.
Water-associated diseases categories:
Waterborne disease
Water-washed disease
Water-based disease
Water related vector borne diseases
Waterborne diseases Several infections enteric or intestinal diseases of man are transmitted through water contamination by fecal matter. Pathogens excreted in water by an infected person include all major categories such as bacteria, viruses, protozoa and parasitic warms. Water acts only as a passive vehicle for the infectious agent. The following are typical examples of waterborne diseases. Bacterial: Typhoid and paratyphoid fever Cholera Salmonellosis Bacillary dysentery (Shigellosis) 10 | P a g e
Viral: Hepatitis A Protozoa: Amoebiasis Giardia Balantidiasis Helminthes: Ascaris and Trichinas Remark: Water borne diseases may also be transmitted by any of the faeco-oral routes: dirty hands, dirty food, dirty water, etc. To prevent the occurrence of waterborne diseases, safe disposal of human excreta
through provision of toilet facilities and water treatment is very essential
Water-washed diseases: These comprise diseases linked to a lack/shortage of water for personal hygiene. Examples of water -washed diseases are: Dermatological disease such as scabies Ophthalmic disease such as trachoma and conjunctivitis Louse-borne diseases such as louse borne typhus and relapsing fever To prevent water washed disease, provision of an ample amount of
safe water and promoting personal hygiene are very essential.
Water-based diseases: These are diseases caused by infectious agents that are spread by contact with water. The essential part of the life cycle of the infecting agent takes place from an aquatic animal. Typical examples: Schistosomiasis (Biliharziasis) and Dracunculiasis (Guinea worm)
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Prevention: Avoid contaminating water with faces or urine, avoid contact with
snail infected water (e.g. swimming), store water for about 48 hours to let cercaria died, for Guinea worm filter water (e.g. clothe filtration)
Water related vector-borne diseases: These are diseases transmitted by insects that live close to water. Infections are spread by mosquitoes, flies and other insects that breed in water or near it. Malaria, Sick sleeping sickness, Yellow fever, Onchocerciasis (river blindness), Leishmaniasis, etc.
To prevent this type of diseases, it is essential to make the water unsuitable
for breeding of insects (vectors).
2.1.2 Water supply standards Water supply standard 1: Access and water quantity All people have safe and equitable access to a sufficient quantity of water for drinking, cooking and personal and domestic hygiene. Public water points are sufficiently close to households to enable use of the minimum water requirement.
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Table 1. A recommended basic water requirement for human domestic needs (Gleick, 1996; 1998)
Purpose
Recommended commitment (liter per person per day)
Drinking water a
5
Sanitation services
20
Bathing
15
Food preparation b
10
a
This is a true minimum to sustain life in a moderate climatic conditions and average activity level b
Excluding water required to grow food. A rough estimate of the water required to grow the daily food needs of an individual is 2700 liters. The WHO and UNICEF (2000) consider as reasonable the availability of at least 20 litres per capita per day (l/c/d) from a source located within one kilometer of the users‟ dwelling. The quantities of water needed for domestic use is context based, and may vary according to the climate, the sanitation facilities available, people‟s habits, their religious and cultural practices, the food they cook, the clothes they wear, and so on. According to the Growth and Transformation Plan (GTP) of Ethiopia, a household in the rural area has to have a supply of about 15 liters of safe water per person per day in 1.5 km radius. Similarly, the GTP defines the clean water supply for urban dwellers 20 liters of potable water per person per day within a 0.5 km radius. Queueing time at a water source should be no more than 30 minutes Excessive queueing times are indicators of insufficient water availability due to either an inadequate number of water points or inadequate yields at water sources. The potential negative results of excessive queueing times are reduced per capita water consumption, increased consumption from unprotected surface sources and reduced time for other essential survival tasks for those who collect water. 13 | P a g e
Water supply standard 2: Water quality Water should be palatable and of sufficient quality to be drunk and used for cooking and personal and domestic hygiene without causing risk to health.
Even though water may look clear, it does not necessarily mean that it is safe or otherwise suitable for us to drink. It is important to judge the quality of water by taking the following three aspects into consideration:
Biological: bacteria, viruses, protozoa and worms.
Chemical: minerals, metals, pesticides, and other chemicals.
Physical: temperature, colour, smell, taste and turbidity. The great majority of evident water-related health problems are the result of microbial (bacterial, viral, protozoan or other biological) contamination. Nevertheless, an appreciable number of serious health concerns may occur as a result of the chemical contamination of drinking water (WHO, 2011).
Palatability: Taste is not in itself a direct health problem, but if the safe water supply does not taste good, users may drink from unsafe sources and put their health at risk. To avoid this, hygiene promotion activities are needed to ensure that only safe supplies are used. Post-delivery contamination: Water that is safe at the point of delivery can nevertheless present a significant health risk due to recontamination during collection, storage and drawing. Steps that can be taken to minimize such risk include improved collection and storage practices and distribution of clean and appropriate collection and storage containers. Water supply standard 3: Water facilities People should have adequate facilities to collect, store and use sufficient quantities of water for drinking, cooking and personal hygiene, and to ensure that drinking water 14 | P a g e
remains safe until it is consumed.
2.1.3 Sources of Drinking Water Drinking water sources can be classified as improved and unimproved. An improved drinking water source is one that by the nature of its construction and design adequately protects the source from outside contamination, in particular by faecal matter. Unimproved drinking water sources are considered unsafe for human consumption and/or other domestic purposes. Improved drinking water sources are:
Piped water on premises - such as piped household water connection located inside the user‟s dwelling, plot or yard.
Other improved drinking water sources: public taps or standpipes, tube wells or boreholes, protected dug wells, protected springs, and rainwater collection.
Unimproved drinking water sources are:
unprotected dug well,
unprotected spring,
cart with small tank/drum provided by water vendor
tanker truck provision of water
surface water (river, dam, lake, pond, stream, canal, irrigation channels), and
bottled water (water for other domestic purposes will be from other unsafe sources). Remark: bottled water is a source of improved drinking water only when another improved source is also used for cooking and personal hygiene.
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2.2 Water Supply Current Status (WHO & UNICEF, 2014) Global:
In 2012, 89% of the global population used an improved source of drinking water.
Although the world met the MDG drinking water target, 748 million people - mostly the poor and marginalized - still lack access to an improved drinking water source.
Of these, almost a quarter (173 million people) rely on untreated surface water, and over 90% live in rural areas.
If current trends continue, there will still be 547 million people without an improved drinking water supply in 2015.
Most countries in sub-Saharan Africa are not on track to meet the MDG water target
Ethiopia: Table 2. Access to Improved Drinking Water Sources Access to Improved Drinking Water Sources Setting
1990
2000
2012
Rural
3%
19%
42%
Urban
81%
87%
97%
National
13%
29%
52%
Ethiopia is on track to meet MDG target for drinking water
Points of discussion:
What is the coverage of improved water supply in your catchment area?
What are the top ten diseases in your catchment area? Among these, which are water associated diseases?
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What about functionality and quality of water supply sources?
Why constructed water supply systems are not functional?
Why people still use unsafe water sources while there are protected sources?
Why protected water sources still did not improve the community health? water quality
Water supply systems for rural communities
Spring water
Well water
Rain harvesting
Zoned stream/river
This manual will focus on the first three water sources as these are improved sources of water. Spring water A spring can be defined as a place where a natural groundwater flow occurs. Spring water is usually fed by and aquifer or a water flow through fissured rock. Water is forced up flow to the surface where solid or clay layer block the underground flow and the water can easily be tapped where it emerges.
The first step is the identification of the spring source.
The second important step is to carry out a feasibility study of a spring source, to provide the information and data to design a water supply system. Local people are important sources of information and should be involved in decisions about the feasibility of developing a particular spring. A proper feasibility study of a spring source should last at least one year. Aspects to be considered are:
The potential environmental impact of developing a spring, including risks of landslides, erosion, human activities that can cause a contamination of the source, presence of undesirable trees and plants.
The spring water quality, including thickness of the soil layer, type of soil and velocity of infiltration of the surface water. If the soil is not thick enough, and human activity should be restricted in the catchments area.
The spring water quantity in terms of flow rate and consistency. Variation in the yield of a spring during dry and rainy seasons in an important criterion to determine if the spring is a suitable source: the ratio between the highest and the lowest should be
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below 20. Yield is measured in l/s and the measurement process involves two selected trained villagers who measure the discharge from the spring over the study period.
The final step is the design and construction of a spring-fed water supply for a specific location. The major components in the design of the system include the actual spring collection area, where water from the aquifer is actually being channelled to a single discharge point, the supply pipe, the collection chamber and the outlet to a storage tank. The design must be appropriate to the specific local conditions, prevent pathogenic contamination and pollution, have no adverse environmental impact and be reliable in terms of quantity. You can consult the local environmental health officers or other relevant experts for the design issues and construction. The most importantly, you are expected to participate in site selection and mobilizing the community during new water supply source construction.
Protection of spring water from pollution 1. Ensure that the spring does not dry up during dry season. 2. Ensure that there are no pollutions such as latrine and waste dump above the spring site. 3. Clean the surrounding of the spring. 4. Collect the eye of the spring, if scattered in one place by digging. 5. After ensuring the eye of the spring is reliable, dig around the eye and build protection box. 6. The protection box built around the eye of the spring must be dry wall. 7. Put at the floor of the spring clean gravel. 8. The protection box built around the eye should have intake pipe which would take the water storage to the tank. The intake pipe must be placed at convenient location to take out the spring water. 9. When laying intake pipe, it should be sealed properly not to leave spot for leakage. 10. This must be done by keeping the gradient for the flow of spring water. The intake pipe should be placed lower than the eye of the spring. 11. The over flow pipe must be placed direct to the edge of the spring. 12. The overflow pipe must be placed at least 50 cm. above the protection box wall. 18 | P a g e
13. The over flow pipe must be placed 20 cm. above the intake pipe. 14. The cover of the protection box must be 60 cm. by 60 cm. in order to clean the eye of the spring as desired. 15. Put properly, cut pole around the eye when pouring the concrete wall. This should be taken out when the concrete wall dries up. 16. After laying the pole, place 12 mm wire at 20 cm distance apart and tie them up with thin wire. 17. When building protection box around the eye of the spring, care should be taken to avoid leakage of the water around the sides of intake pipe. And build protection wall plastered with concrete to avoid change of direction of the spring water. 18. If the yield of the spring is high, and the number of users is few, then it is possible to build a collection or storage box for the spring water. Similarly if the condition is the other way round it is better to build storage tank to collect the water.
Selection of site for digging and how to protect pollution of well water 1. The well site should be at least 30 meters away from sources of contaminants and should
be on the upper gradient of the surrounding. Remark: The minimum safe distance between the well and potential sources of pollution will vary depending on the local conditions, particularly the soil type, geology, hydraulic gradient and slope of the land. It should never be less than 15 metres but 30-50 metres is recommended.
2. To strike ground water quickly dig on the lower level of the area and clean the surrounding. 3. Dig the well in round shape with radius of 40 cm. until water level is reached. 4. In order to avoid entry of flood, build with stone and cement casing to the depth of 3 meters from top to down-ward, and raise the mouth of the well by raising 30 cm. above the surrounding level by stone and cement. If stone is not available, use bricks. 5. In order to prevent caving in of the pit, put barrel, wooden material or large mouth clay. 6. To prevent dirt entering from the top, cover should made 19 | P a g e
7. To prevent flood entry, the surrounding of the well should be graded off to divert the flow of storm water into the well. 8. In order to prevent pollution of well water by dipping contaminated bucket and rope, plant two angled pole on opposite sides of the well and place a horizontal pole over the angled one by criss-crossing and put around this rope long enough to reach the level of the well water. Connect the bucket to this rope. The bucket and rope are dipped into the well to draw water from the well. This prevents the bucket and rope from contaminating the well water. 9. After drawing water from the well, it must be covered properly with corrugated iron sheet to avoid contamination. 10. Better to have a pad lock on the cover to prevent children from meddling and falling into the well. 11. Fence around the well to prevent intrusion of animals into the well. 12. People should be careful before entering into the well to clean it. The well has to be aerated by removing the cover for a fixed period. When a person enters into the well, the wall may collapse, better to tie around the person entering the well rope to avoid accident of fall. 13. When the yield of the well decreases, dig deeper the well to increase the yield paying attention to the above described points. Rainwater harvesting
Rainwater harvesting consist in capturing the rain where it falls or capturing and storing the runoff in farms, villages and towns. Measures should also be taken to keep the water clean. This technique was used widely for the provision of drinking water in rural areas. Rainwater harvesting should be considered as a source of domestic water in countries where rain comes in storms of considerable intensity. It is used in many different ways: in some parts of the world only a small storage capacity is required, in arid areas a sufficient large collection surface area and storage capacity will be required to provide enough water.
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Rainwater harvesting can consist of a collection surface, a storage tank, and guttering or channels to transport the water from one to the other. Sometimes it includes a first-flush system to divert the initial dirty water that contains roof debris built up during prolonged dry periods, filtration equipments and settling chambers. A wide variety of systems are available for treating water before, during and after storage. Filters are often use for filtering water entering a tank and use sand, stone, gravel or charcoal or a combination of these as filter material. The storage tank is usually the biggest capital investment element of a rainwater harvesting system for domestic water, it therefore require the most careful design to provide the best capacity with the lowest cost as possible. For larger storage volumes, tanks or cisterns constructed of brick or stone masonry are used most.
When designing a water harvesting system the main calculation is to size the water tank, cistern or dam correctly to give adequate storage capacity. The storage requirements depend upon local rainfall data, collection surface, runoff coefficient, user numbers and consumption rates or water needs for productive use. The simplest method to calculate the required water volume is to use the following formula: V = (t x n x q)
Where ;
V: volume of the tank t: number of days in dry period n: number of people using the tank q: total average consumption per capita per day (including all uses).
Rainwater harvesting has a beneficial effect for family heath, because women and other drawers of water spend less time collecting water so to save time for other households tasks, water is available at the home yard, so the risk of accident for children and women is lower, and finally the use of more, clean and safe water has several health benefits. Contamination of water might arise from the roofing material itself or from substances that have accumulated on a roof or in a gutter. A common strategy is to divert to waste the first litres of runoff at the
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beginning of every rainfall.
A sanitary survey A sanitary survey is an assessment of conditions and practices that may constitute a public health risk. It covers possible sources of contamination to water at the source in transport and in the home, defecation practices, drainage and solid waste management. Note that while animal excreta is not as harmful as human excreta, it can contain micro-organisms, such as cryptosporidium, giardia, salmonella and other common causes of human diarrhoea, and therefore presents a significant health risk. Health extension workers are expected to conduct sanitary survey of water supply sources and intervene through community mobilization. The specific functions of the sanitary inspection are to: identify potential sources and points of contamination of the water supply; quantify the hazard (hazard score) attributable to the sources and supply; provide a clear, graphical means of explaining the hazards to the operator/user; provide clear guidance as to the remedial action required to protect and improve the supply; provide the raw data for use in systematic, strategic planning for improvement.
The following sample sanitary survey checklists are adapted from WHO guidelines for drinking water quality (WHO, 1997).
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Table 3. Checklist for open dug well water (rope and bucket system) sanitary inspection Specific diagnostic information for assessment
Risk
1. Is there a latrine within 10 m of the well?
Y/N
2. Is the nearest latrine on higher ground than the well?
Y/N
3. Is there any other source of pollution (e.g. animal excreta, rubbish) within 10 m of the well?
Y/N
4. Is the drainage poor, causing stagnant water within 2m of the well?
Y/N
5. Is there a faulty drainage channel? Is it broken, permitting ponding?
Y/N
6. Is the wall around the well inadequate, allowing surface water to enter the well?
Y/N
7. Is the concrete floor less than 1m wide around the well?
Y/N
8. Are the walls of the well inadequately sealed at any point for 3m below ground?
Y/N
9. Are there any cracks in the concrete floor around the well which could permit water to enter the well?
Y/N
10. Are the rope and bucket left in such a position that they may become contaminated? 11. Does the installation require fencing?
Y/N Y/N Total score of risks ............... /11
Contamination risk score: 9–11 = very high; 6–8 = high; 3–5 = intermediate; 0–2 = low
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Table 4. Checklist for covered dug well with hand-pump sanitary inspection Specific diagnostic information for assessment
Risk
1. Is there a latrine within 10 m of the well and hand-pump?
Y/N
2. Is the nearest latrine on higher ground than the hand-pump?
Y/N
3. Is there any other source of pollution (e.g. animal excreta, rubbish) within 10m of the hand-pump?
Y/N
4. Is the drainage poor, causing stagnant water within 2m of the cement
Y/N
floor of the hand-pump? 5. Is there a faulty drainage channel? Is it broken, permitting ponding?
Y/N
6. Is the wall or fencing around the hand-pump inadequate, allowing animals in?
Y/N
7. Is the concrete floor less than 1m wide all around the hand-pump?
Y/N
8. Is there any ponding on the concrete floor around the hand-pump?
Y/N
9. Are there any cracks in the concrete floor around the hand-pump which could permit water to enter the hand-pump?
Y/N
10. Is the hand-pump loose at the point of attachment to the base so that water could enter the casing?
Y/N
11. Is the cover of the well unsanitary?
Y/N
12. Are the walls of the well inadequately sealed at any point for 3m below ground level?
Y/N Total score of risks ............... /12
Contamination risk score: 9–12 = very high; 6–8 = high; 3–5 = intermediate; 0–2 = low
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Table 5. Checklist for protected spring source inspection Specific diagnostic information for assessment
Risk
1. Is the spring source unprotected by masonry or concrete wall or spring box and therefore open to surface contamination?
Y/N
2. Is the masonry protecting the spring source faulty?
Y/N
3. If there is a spring box, is there an unsanitary inspection cover in the masonry?
Y/N
4. Does the spring box contain contaminating silt or animals?
Y/N
5.
If there is an air vent in the masonry, is it unsanitary?
Y/N
6.
If there is an overflow pipe, is it unsanitary?
Y/N
7.
Is the area around the spring unfenced?
Y/N
8. Can animals have access to within 10 m of the spring source?
Y/N
9. Does the spring lack a surface water diversion ditch above it, or (if present) is it nonfunctional? 10. Are there any latrines uphill of the spring?
Y/N Y/N Total score of risks ............. /10
Contamination risk score: 9–10 = very high; 6–8 = high; 3–5 = intermediate; 0–2 = low
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Table 6.Checklist for rainwater collection and storage inspection Specific diagnostic information for assessment
Risk
1. Is there any visible contamination of the roof catchment area (plants, dirt, or excreta)?
Y/N
2. Are the guttering channels that collect water dirty?
Y/N
3. Is there any deficiency in the filter box at the tank inlet (e.g. lacks fine gravel)?
Y/N
4. Is there any other point of entry to the tank that is not properly covered?
Y/N
5. Is there any defect in the walls or top of the tank (e.g. cracks) that could let water in?
Y/N
6. Is the tap leaking or otherwise defective?
Y/N
7. Is the concrete floor under the tap defective or dirty?
Y/N
8. Is the water collection area inadequately drained?
Y/N
9. Is there any source of pollution around the tank or water collection area (e.g. excreta)?
Y/N
10. Is a bucket in use and left in a place where it may become contaminated?
Y/N
Total score of risks ............ /10 Contamination risk score: 9–10 = very high; 6–8 = high; 3–5 = intermediate; 0–2 = low
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2.4. Household level water treatment The water sources used for supplying water were not always clean. Household water treatment can help improve water quality at the point of consumption, especially when drinking-water sources are distant, unreliable or unsafe. However, household water treatment should be viewed primarily as a stop gap measure only; it does not replace the obligation of a service provider to provide access to safe drinking water. It is intended for people who have no access to improved drinking-water sources, for people with access to improved sources outside of their home or premises (i.e. when contamination can occur during transport and storage), for people with unreliable piped supplies who have to store water to bridge the gaps between deliveries, and for people in emergency situations (WHO and UNICEF, 2014). The following household level water treatment systems will be addressed in this training.
Disinfection
Sedimentation
Filtration
Disinfection If water is clear but possibly contaminated, it must be disinfected. Household level disinfection is highly advisable when there is diarrheal disease epidemic in the community. This manual will cover three types of disinfection.
Boiling
Solar
Chemical
Boiling
Boiling is a traditional method of treating water.
If done properly it can provide safe water to a population that has no alternatives.
Boiling will kill all germs that cause disease
Boiling water is something people can do themselves
Boiling has no residual effect, so improper storage can lead to re-contamination.
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Boiled water should be stored safely and used within a few days. Boiling is only effective if the temperature is high enough.
Boiling will make the water taste flat. However, this can be fixed by shaking the water in a bottle.
Solar disinfection:
Exposing water to sunlight will destroy most germs that cause disease. This is even more effective at higher temperature although the temperature of the water does not need to rise much above 50°C.
One easy method of treating the water is to expose plastic or glass bottles of water to the sun. For greater effectiveness place the bottle on a corrugated-iron roof.
In tropical regions, a safe exposure period is about five hours per day, centered around midday. The amount of time the bottle is exposed to the sun will need to be doubled (two days instead of one) when the water is cloudy. The exposure time should also be increased if there is not sunny weather (rainy season).
Figure 1: Solar disinfection
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Solar disinfection has positive and negative aspects.
Solar disinfection will kill most germs that cause disease if exposed to the sun long enough.
Solar disinfection is something people can do themselves with widely available materials (clear bottles or clear plastic bags).
Solar disinfection has no residual effect, so improper storage can lead to recontamination. Water treated by this method should be stored safely and used within a few days.
Solar disinfection takes more time than other methods and requires sunny weather.
People are unlikely to like to drink the warm, treated water. Encourage them to let it cool.
Chemical disinfection:
Chlorine is the common chemical disinfectant of choice and available in different phases and concentration
Toxic to consumers if the dose is higher
Chlorination by products can also result in cancer if organic matter is high (turbid )
Consult the environmental health offices in your district if you want to apply chlorine for disinfection. Disinfection can often affect the taste of water.
Boiling will leave the water tasting flat.
Solar will make the water hot.
Chemicals can leave a bad taste. But all of these problems can be overcome by simple methods.
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Filtration (Simple household filters) There are many different types of household filter, some produced commercially and others that can be manufactured locally. Most will remove a high proportion of solids and silt. Many will also remove parasites including cysts, ova, and guinea worm larvae, but some simple filters may not remove all microorganisms from water. The various types of simple household filter are sand filters, candle filters and stone filters.
Homemade sand filter: Having a reliable source of clean water is one of the most important factors in staying healthy. It‟s also a major challenge in many areas, both in cities and rural communities. Boiling water is a good way to purify it of harmful organisms, but is costly in fuel or firewood. But water can also be cleaned by making it flow through layers of gravel and sand. This not only removes large particles (ova, larvae, cysts, and Cyclops species) but also removes or kills much smaller organisms, including viruses and bacteria. A simple water filter made from local resources primarily sand, gravel and cement/barrel remove over 90% of many common water-borne pathogens. Because bacteria and viruses are not completely removed, additional treatment such as disinfection (usually with chlorine) may be desirable after filtration. Through community-based training several countries, including Kenya, Uganda, Zambia and Sudan, some groups have even started using the filters to generate income from sales of clean water. Therefore, it is possible to do so in Ethiopia too.
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Figure 2: Homemade sand filter
Candle filters: Candle filters are often commercially produced. In this type of filter, contaminated water is allowed to filter slowly through a porous ceramic material. Larger microorganisms - ova, cysts, and most bacteria - are left in the outer layer of the filter material, which is periodically cleaned by gently scrubbing the filter under clean, running water. Smaller microorganisms, such as the virus that causes hepatitis A, may not be removed by candle filters. This might be higher in terms of cost but you can still suggest for households who can afford it.
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Figure 3: Candle filter
Cloth filtration to prevent guinea-worm disease: Guinea-worm disease (dracunculiasis) is transmitted via contaminated drinking water (e.g. from stagnant ponds, cisterns, or step wells). Infected individuals do not develop immunity. There is no known animal reservoir, and people can disseminate the parasite 1 year after infection and during 1-3 weeks after emergence of the worm. Guinea worm (Dracunculus medinensis) can be effectively eliminated by filtering all drinking-water through fine cloth Filtration of drinkingwater is thus a primary strategy for the control of guinea-worm disease. Filters should be of mesh size less than 130mm and this should remove all infected intermediate hosts. Monofilament synthetic cloth (nylon) is most suitable because it clogs less rapidly and is easily cleaned; it has a mesh size of 100-130mm. Cotton cloth can be used but tends to clog rapidly.
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Figure 4: Cloth filtration
Household water treatment technology selection criteria There are several criteria that one should take into consideration when deciding which household water treatment technology is most suitable. Some of these include: 1. Effectiveness: How well does the technology perform? 2. Appropriateness: How well does the technology fit into people‟s daily lives? 3. Acceptability: What will people think of the technology? 4. Cost: What are the costs for the household? 5. Implementation: What is required to get the technology into people‟s homes? Effectiveness: Effectiveness is the ability of the technology to provide sufficient water quality and quantity. There should be enough safe drinking-water for a household to meet its basic needs. Criteria that show the technology‟s effectiveness include the following: Water quality Which microbiological, physical and chemical contaminants can be removed by the technology and how much? Water quantity How much water can be provided every day? Is it sufficient to meet the household‟s daily needs? 33 | P a g e
Local water source Will the technology be able to treat the specific microbiological, physical and chemical contaminants of the local water source? Will it treat water from different sources to the same level? Appropriateness: Some technologies will be more suitable than others depending on the needs and conditions of the community. Answering the following criteria can help to match a technology with a particular community: Local availability Can the technology be manufactured in or near the community using local materials and labour? Does the technology need imported spare parts or consumables? Is it possible to buy spare parts or consumables locally? Is the supply chain reliable? Time How long does it take for a household to treat enough water to meet their daily needs? Does it significantly add to the household‟s labour burden? Operation and maintenance What are the household‟s responsibilities to operate and maintain the technology? Is it easy and convenient for women and children to use the technology? Life span How long will the technology last before it needs to be fixed or replaced? Acceptability: People‟s opinion about the technology will affect its widespread adoption and consistent use. It is difficult for many people to accept a new technology until they personally experience the benefits. People‟s acceptance of a technology is affected by the following criteria: Taste, smell and colour How will the treated water look, taste and smell? Needs and motivations? What benefits will the technology give to people? 34 | P a g e
Will it provide convenience, health improvement, social status, time or money savings? Cost: Most household water treatment options are not free. Successful cost recovery is an important part of the programme sustainability. The following costs need to be considered: Capital costs Initial purchase of a durable product. Transportation. Ongoing costs Continuing purchase of consumable products. Operation and maintenance. Potential repair and replacement parts Willingness to pay and affordability Can households afford the full cost of the technology? Are households willing to pay for capital costs? Are households willing to pay for on-going operation and maintenance costs? How is technology impacted by household income fluctuations? Do durable or consumable items need to be subsidized? Implementation costs Cost to run the programme (e.g. staff, office space). Cost to raise awareness in the community. Cost to educate people about how to use the technology. Cost to provide ongoing support for households.
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How is water contaminated? Every step in the chain presents an opportunity for water to be contaminated. Water can be contaminated at the source, in the home, or during the journey in between. A water source that is not protected, a dirty container, or unwashed hands can easily turn water, even water that looks and tastes clean, into something that makes people ill. A water source can be contaminated through a number of routes including:
Leaking septic tanks and latrines.
Contaminated surface water run-off entering wells and springs.
Collecting water with unwashed hands and/or dirty containers.
Animals using the same source.
Objects falling into the well.
However, the water at the source is only the first stage of the water chain. Even clean water collected from a source can be contaminated prior to use at critical points due to unsafe hygiene practices:
Transporting water from the source to the house in dirty water containers.
Storing water at home in open and/or dirty water containers.
Handling water at home with dirty utensils or hands.
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2.5. Household water storage The principal health risk associated with household water storage is the ease of recontamination during transport and storage, particularly where the members of a family or community do not all follow good hygiene practice. Good hygienic measures include the following:
careful storage of household water and regular cleaning of all household waterstorage facilities;
construction, proper use, and maintenance of latrines;
regular hand-washing, especially after defecation and before eating or preparing food;
careful storage and preparation of food.
Water that is clean from the supply or has been treated in the household needs to be protected from recontamination. The following precautions and considerations are important:
Location of storage vessel: The storage vessel should be placed above ground level to restrict access by children and animals. It should preferably be placed in a shaded position to keep the water cool, and should be accessible to users and for refilling. Design of storage vessel: The storage vessel should be designed to reduce the risk of contamination: it should have a secure, tight-fitting lid, be robust enough to withstand rough handling without cracking, and be easy to lift from the ground and carry back to the storage point after filling. Stored water may be kept cool by using earthenware jars or pots; these allow some water to evaporate, which has a cooling effect. Containers should be easy to fill and clean, so that contact with hands is minimized. Removal of water: It should be possible to remove water from the container hygienically, with no contact between hands and the water. Water is commonly withdrawn by means of a cup. This may be acceptable where the cup is not used for any other purpose, is cleaned regularly, and is stored where contamination cannot occur. However, as it is difficult to dip the cup into the water without also putting in the hands, the risk of contamination is still high. It is better to use a ladle that is stored permanently inside the container; this reduces the risk of contamination while the ladle is not in use. However, the ladle should be used only to transfer water to a cup or other vessel. 37 | P a g e
Substances such as petrol, diesel fuel, pesticides, and solvents should not be stored or used near water facilities (sources, catchments, storage tanks, etc.). Containers that have been used for the storage, transport, or handling of these substances should not subsequently be used to store water intended for human consumption, even after thorough cleaning. The most important elements of water storage can be summarized as follows: •
Use a clean water source or treat the water, either at home or in a storage tank.
•
Store water in an earthenware or plastic container with a lid.
•
Store the water container at a height that puts it beyond the reach of children and animals.
•
Fit a tap to the container for drawing clean water in order to prevent contamination by dirty cups, ladles, or hands.
•
Fit a tap to the container for drawing clean water in order to prevent contamination by dirty cups, ladles, or hands.
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UNIT THREE: SANITATION
Unit objective: After completing this unit the participants will be able to describe the broad concepts of sanitation, F-diagram and sanitation facility applicable for rural community Learning Objectives: To meet the unit objective the participants will: Define sanitation State the sanitation vision and sanitation pillars Elaborate link between sanitation and different diseases Describe the F-diagram and the barriers Identify sanitation facility applicable for rural community
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3.1. Introduction to sanitation The sanitation vision of Ethiopia is 100% adoption of improved (household and institutional) sanitation and hygiene by each community which will contribute to better health, a safer, cleaner environment, and the socio-economic development of the country. Where there are no latrines people resort to defecation in the open. Open defecation rates decreased from 92% in 1990 to 37% in 2012 (i.e. 55% per cent reduction in open defecation practice). Open defecation encourages flies, which spread faeces-related diseases. Surface water run-off from places where people have defecated results in water pollution. In view of the health hazards created and the degradation of the environment, open defecation should not be tolerated in villages and other built-up areas. There are better options available that confine excrete in such a way that the cycle of re-infection from excrete-related diseases is broken.
There are Three Strategic Pillars for Improved Sanitation and Hygiene these are: Pillar 1. An enabling framework to support and facilitate an accelerated scaling-up through policy consensus, legislation, political commitment, inter-sectoral cooperation, partnership, capacity building linked to performance contractual agreements, supportive supervision, research and monitoring. Pillar 2. Sanitation and hygiene promotion through participatory learning, advocacy, communication, social marketing, incentives or sanctions to create demand and forge behavior change. Pillar 3. Improved access to strengthen the supply of sanitation through appropriate technology solutions, product and project development, and support to local producers and artisans.
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According to the Joint Monitoring Programme (JMP) for Water Supply and Sanitation (WHO and UNICEF, 2014), improved sanitation and unimproved sanitation grouped as follow: Improved sanitation include : • Flush/pour flush to: piped sewer system septic tank pit latrine • Ventilated improved pit (VIP) latrine •
Pit latrine with slab
•
Composting toilet
Unimproved sanitation includes: Facilities that do not ensure hygienic separation of human excreta from human contact.
Shared sanitation facilities: Sanitation facilities of an otherwise acceptable type shared between two or more households.
pit latrines without a slab or platform,
hanging latrines
bucket latrines
Open defecation: when human faeces are disposed of in fields, forests, bushes, open bodies of water, beaches or other open spaces or disposed of with solid waste.
3.2. Sanitation and disease transmission The inadequate and insanitary disposal of infected human faeces leads to the contamination of the ground and of sources of water. Often it provides the sites and the opportunity for certain species of flies and mosquitoes to lay their eggs, to breed, or to feed on the exposed material and to carry infection. It also attracts domestic animals, rodents and other vermin which spread the faeces and with them the potential for disease. In addition it sometimes creates intolerable nuisances of both odour and sight. There are a number of diseases related to excrete and wastewater which commonly affect people in the developing countries are intestinal infections and helminth infestations, including cholera, typhoid and paratyphoid fevers, dysentery and 41 | P a g e
diarrhoea, hookworm, schistosomiasis and filariasis. Safe excreta disposal is the option for controlling the problem. Those most at risk of these diseases are children under five years of age, as their immune systems are not fully developed and may be further impaired by malnutrition.
Figure 5: "F" diagram and barriers
3.3. Sanitation Facility Selecting the most appropriate sanitation facility requires a thorough analysis of all factors including cost, cultural acceptability, simplicity of design and construction, operation and maintenance, and local availability of materials and skills. There are different sanitation facility
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in the world where they do have their own advantages and disadvantages. The most widely rural community practice is open defecation as shown in the Figure 6.
Figure 6: People practicing open defecation There is no advantage of open defecation
3.3.1. Cat/Scrap Latrine A cat/scrape latrine is an improvement from open defecation. It is a shallow hole or scrape in the ground which is covered over with earth after defecation. This type of improved open defecation may be appropriate for nomadic or semi-nomadic groups where the construction of a permanent latrine may not be an option. It may also be appropriate in areas with very low population densities where the chance of contacting the excreta is minimal.
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Excavation Hoe or other tool
Excavated soil
Ground level Gnd Level 15cm
20cm
Figure 7: Cat/Scrap Latrine
Advantages
Limitations
No cost
Easy to do
Feces are buried and less accessible
Suitable for scattered populations in hot dry
Must carry a digging tool when going to defecate
Burial depth may not prevent flies from accessing excreta
climates
Not suitable for crowded environments
Does not need water
Fly nuisance
Can be used as fertilizer
Spread of disease e.g. larvae of hook worm
3.3.2. Arborloo latrine An Arborloo latrine is an eco sanitation option. It uses one shallow pit (1 meter deep) for composting excreta, which is then used to grow a tree when the pit is full. The superstructure, slab and footing are portable, so that when the pit is full (i.e. within 0.5 meters from the top), the structure can be moved to a new pit. The pit typically fills in about six to nine months. The full pit is topped with soil and a fruit bearing or fuel wood tree is planted in the nutrient rich soil. Recommended areas:
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Limited water supply, space for an orchard and multiple pits
Human excreta accepted as fertilizer for fruit or fuel wood trees
Recommended areas:
Limited water supply, space for an orchard and multiple pits
Human excreta accepted as fertilizer for fruit or fuel wood trees
Figure 8: Arborloo latrine
Advantages
Inexpensive to construct and most parts are re-
Limitations
usable
No direct contact with excreta
No water needed (except for cleaning)
Can be used by washers and wipers for anal
must be added regularly
Pit excavation is small and shallow
Orchard or fuel wood grove is developed over time
Space is required for planting trees after pit is full
cleansing
Ash, lime, sawdust, earth, or vegetable matter
Space is required to relocate the latrine on a regular basis
Frequently need to dig a new pit and reinstall superstructure
May be culturally unacceptable to use human excreta for this purpose
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3.3.3.. Simple pit latrine
This consists of a slab over a pit which may be 2 m or more in depth.
The slab should be firmly supported on all sides and raised above the surrounding ground so that surface water cannot enter the pit. If the sides of the pit are liable to collapse they should be lined and a squat hole in the slab or a seat is provided so that the excrete fall directly into the pit.
The basic pit latrine is one of the most common low cost sanitation options.
It is a rectangular or circular pit dug into the ground, covered with a slab or platform with a drop hole in it, and usually has some sort of screen around it for privacy.
The slab is often made of concrete but can also be made of wood poles covered with compacted earth.
The pit must be lined if it is intended to be emptied. Smells, flies and other pests will be reduced if the latrine is well maintained, the slab kept clean, and the hole covered.
Simple pit latrines are cost effective for most communities and an important tool in reducing the spread of diarrheal disease.
Recommended Areas:
Groundwater depth greater than 3 meters
Permeable soil
Community objects to the use of excreta as a fertilizer
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Figure 9: Simple Pit Latrine
Advantage
Disadvantage
Low cost
Considerable fly nuisance (and mosquito
Easley built by the owner
nuisance if the pit is wet) unless there is a
No water is needed
tight-fitting cover over the squat hole when
Easily understood
the latrine is not in use Smell
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Some Examples of Pit latrines which are not functional
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Figure 10: Non functional pit latrines (( Photo taken from undergraduate out reach report, 2014). Note. All the above observed pictures are assumed as sanitation facility where they do not have durable construction material, no privacy, easy for demolition, flooding can easily affect etc.
Dear trainees, what is your experience on the general pit latrine condition in your working environment, please share your experience to others!
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3.3.4. Borehole latrine
A borehole excavated by hand with an auger or by machine can be used as a latrine.
The diameter is often about 400 mm and the depth 6- 8 m.
Figure 11: Borehole latrine Advantage
Can
Disadvantage be
excavated
quickly
if
boring
equipment is available
Sides liable to be fouled, with consequent fly nuisance
Suitable for short-term use, as in disaster
Short life owing to small cross sectional area
situations
Greater risk of groundwater pollution owing to depth of hole
3.3.5. Ventilated pit latrine The Ventilated Improved Pit Latrine (VIP) is a modification of the simple pit latrine. The vent pipe and open drop hole (do not use a lid!) help keep air flow through the structure which reduces odours. Fresh air comes into the superstructure through the air vent, down through the drop hole and out the vent pipe. Because the latrine is kept dark, any flies in the pit are attracted to the light at the top of the vent pipe, where they are trapped by the fly screen and die. Recommended Areas : Groundwater depth greater than 3 meters, Permeable soil, Community objects to the use of excreta as a fertilizer
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Figure 12: VIP latrine Advantage
Disadvantages
Low cost
Does not control mosquitoes
Can be built by householder
Extra cost of providing vent pipe
Needs no water for operation
Need to keep interior dark which can
Easily understood
Control of flies
Absence of smell in latrines
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be scary for children
Operation and Maintenance
The door should always be kept closed and clean the slab regularly
Check the screen at the top of the vent pipe annually and replace as needed; without the screen there is no fly control
Empty or fill in pit when excreta is within 0.5 meters of the slab
3.3.6. Compost latrine In rural and low-density urban areas, the usual practice is to dig a second pit when the one in use is full to within half a meter of the slab. If the superstructure and slab are light and prefabricated they can be moved to a new pit. Otherwise a new superstructure and slab have to be constructed. The first pit is then filled up with soil. After two years, faeces in the first pit will have completely decomposed and even the most persistent pathogens will have been destroyed. When another pit is required the contents of the first pit can be dug out (it is easier to dig than undisturbed soil) and the pit can be used again. The contents of the pit may be used as a soil conditioner. Alternatively, two lined pits may be constructed, each large enough to take an accumulation of faecal solids over a period of two years or more. One pit is used until it is full, and then the second pit is used until that too is full, by which time the contents of the first pit can be removed and used as a fertilizer with no danger to health. The first pit can then be used again.
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Figure 13: Single and double pit Advantage of single pit
Will last for several years if large
Advantage of double pit
enough
A valuable humus is produced
Once constructed the pits are more or less permanent
Easy removal of solids from the pits as they are shallow
Pit contents can be safely used as a soil conditioner alter 2 years, without treatment
Careful operation is essential
Urine has to be collected separately in the batch system
Ash or vegetable matter must be added regularly
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3.3.7. Overhung latrine A latrine built over the sea, a river, or other body of water into which excrete drop directly, is known as an overhung latrine. If there is a strong current in the water the excrete are carried away. Local communities should be warned of the danger to health resulting from contact with or use of water into which excrete have been discharged.
Figure 14: Overhung latrine
Advantage
May be the only feasible system for
Disadvantage
Serious health risks
communities living over water
Cheap
3.3.8. Bucket latrine
This latrine has a bucket or other container for the retention of feaces (and sometimes urine and anal cleaning material), which is periodically removed for treatment or disposal.
Excreta removed in this way are sometimes termed as night soil.
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Figure 15: Bucket Latrine Advantage
Low initial cost
Disadvantage
Malodorous
Creates fly nuisance
Danger to health of those who collect or use the night soil
Collection undesirable
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is
environmentally
and
physically
Size determination of Latrine Factors like the size, number of people using it, how much other material (water, refuse) is added to it and what type of anal cleaning material is used affects the life span of a given pit. In African situation 0.025to 0.040 m3 of waste will accumulate each year per user. The estimated depth = P * S *N + 0.5m A Where P = average number of users S = Solid accumulation rate m3 per person per year (0.025 -0.040 m3) N = Minimum useful life required A = Cross sectional area of the pit (based on the plot available) 0.5 m is added into the calculated depth for the service year required because the pit has to be filled with soil when the pit is full up to 0.5 meters from the top.
Dear participants
Please discuss your experience on the type of latrine that are constructed and their advantage and disadvantage observed in your working area?
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What kind of attempt you use to solve the problems?
What best experience do you have to share for others?
3.4. The effect of poor sanitation 1. Health Status It is reported that up to 60 percent of the current disease burden in Ethiopia is attributable to poor sanitation where 15 percent of total deaths are from diarrhoea, mainly among the large population of children under five. 2. Environmental degradation Faeces and urine are a potential (under-exploited) source of compost and fertiliser which could help address decreasing soil fertility and reduce the high cost (both financial and environmental) of chemical fertilisers. They can also be used to produce biogas (a renewable energy source) which as well as safely containing excreta could contribute to reducing deforestation which is a key environmental issue. 3. Educational Performance It is widely believed that a significant number of school days are lost due to diarrhoea. This mainly affects girls who end up staying at home to care for siblings.
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Barrier for effective sanitation in Ethiopia
Poverty
Gender
Low Level of Priority for Sanitation
Water Not Supplied as Part of an Integrated Environmental Health Package
Limited Resources to Promote Sanitation
Unclear Institutional Framework, Roles and Responsibilities
Available Human Resources Under-utilized
Equipped skilled human resources not readily available
Advocacy not prioritized
Badly built latrines (TPLs) give a bad reputation
Technology option for affordable, durable, desirable latrine design options not readily available
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Subsidies have created unrealistic local expectations
Minimum fundable promotion packages not identified
Credit or mutual savings not applied for sanitation
Special needs groups unmet
UNIT FOUR: HYGIENE PROMOTION AND COMMUNITY EMPOWERMENT
Unit objective: After completing this unit the participants will be able to easily understand and describe concepts of hygiene, hygiene promotion and community empowerment Learning Objectives: To meet the unit objective the participants will: Define hygiene, hygiene promotion and its importance Identify approach for community mobilization Identify barriers for effective hygiene promotion Demonstrate the hand washing steps List the critical hand washing times Define the importance of community involvement in hygiene promotion
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4.1 Personal Hygiene Personal hygiene is all the things we do to keep our bodies clean and healthy. Keeping your body clean includes not only bathing and washing your hands, but also taking care of your hair and your teeth, keeping your fingernails clean and trimmed, and making sure to put on deodorant and wear clean clothes. Aspects of personal hygiene are:
Body/skin hygiene
Hand hygiene
Oral hygiene
Head and hair hygiene
Eye and ear hygiene
Foot hygiene
Menstrual hygiene etc
4.1.1. Body hygiene If we don‟t keep ourselves clean, the bacteria in our sweat will grow and smell bad. It is important to keep ourselves clean. If we are clean we will feel better and stay healthier. If we take a bath or shower every day, use deodorant, and wear clean clothes, we will smell good. It‟s especially important to wash the armpits and groin area well, because these parts of the body provide a perfect place for bacteria to grow. Problems that emanate from failing to keep our body clean:
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Scabies
Typhus
Relapsing fever
Bad body smells etc.
Preventive Methods:
Wash body with clean water and soap at least once a weak
Children should be washed with clean water and soap on a daily basis
Washed or clean clothes should be dressed after washing the body
Figure 16: How to keep personal hygiene
4.1.2. Hand hygiene Hands are easily contaminated by germs if we do not regularly wash and cut our finger nails. Diseases that come from failing to keep the hygiene of the hands and finger nails: Diarrhea and bloody diarrhea Ascariasis Cholera Trachoma Amoebiasis Typhoid etc 61 | P a g e
Preventive methods: Wash hands at critical times
Critical hand washing times:
Before food preparation
Before serving food
Before food and breast feeding of child
After cleaning of child anal and handling of excreta if any,
After visiting latrine and after we perform any cleaning in the surround environment like animal dung and any other waste materials
How to wash hands thoroughly: Hands should be washed with soap and under water for at least 20 seconds. Special attention needs to be paid to germs that may be trapped under nails and in crevices. The arrows in the pictures below show the direction of movement of the hands.
Figure 17: How to wash hands thoroughly 62 | P a g e
Figure 18: How to keep our hands clean
4.1.3 Teeth Hygiene When brushing your teeth remember the following:
Use a soft toothbrush and replace it when it‟s worn.
Brush at least twice a day – in the morning after breakfast and before going to bed.
Brush all of your teeth, not just the ones at the front.
Brush all sides of your teeth, insides, outsides, and on top.
Brush away from your gums.
Take your time. Brush your teeth for 2 minutes.
Then brush your tongue a few times. It’s also really important to floss your teeth because food particles and bacteria get stuck between our teeth. Floss once every day.
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Figure 19: How to keep our teeth clean Bad breath: is usually caused by bacteria growing in the mouth. The inside of your mouth is the perfect place for bacteria to live and grow. It is dark, wet and warm. Odor-causing bacteria can grow and cause bad breath.
Figure 20: What to do to have good smell
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4.1.4. Eye hygiene The eye is a body part that requires maximum care. Health problems related to the eye can be created by dusty air and flies.
Health problems: Trachoma Reddening of the eye (conjunctivitis) Prevention methods: Wash face with clean water and soap in the morning Dry washed hands and eyes with towel or dry clothes Eyes should not be touched with hands. Wash with clean water and soap on a daily basis and as return from work. Get treatment from a nearby health facility for any eye illness
4.1.5. Hair hygiene Hair that isn‟t clean will look oily and can smell bad too. Hair starts smelling bad because of the bacteria and perspiration on it. As the bacteria grow they start to stink, just like the bacteria on your skin do.
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Figure 21: How to keep our hair clean
4.1.6. Foot hygiene Our foot is exposed to different health problems unless it is properly kept clean. Health problems: Hook worm (penetrates through the bare foot) Tetanus Chigger Bad smells Piercing and cut by sharp ends Wounds Bites by insects and others Fungus etc. Preventive methods: Washing foot with clean water and soap on daily basis Wearing shoes Washing foot wears on a regular basis (if washable) Cutting short the finger nails on time 66 | P a g e
4.1.7. Clothes hygiene Clothes that are not clean contribute to the multiplication of pests and the spread of pests borne diseases. The problems include: Typhus Relapsing fever Bad smell Body itching and ulceration etc Prevention: Frequent washing/regular washing out door drying and if possible ironing and putting in clean places Boiling for at least 10 minutes and outdoor drying of all clothes that have produced lice.
4.1.8. Menstrual Hygiene
Menstruation is a natural part of the reproductive cycle, in which blood is lost through the vagina.
Girls typically start to menstruate („the time of menarche‟) during puberty or adolescence, typically between the ages of 10 and 19.
Menstruation continues until they reach menopause, when menstruation ends, usually between their late forties and mid fifties
Globally, approximately 52% of the female population (26% of the total population) is of reproductive age.
Most of these women and girls will menstruate each month for between two and seven days. However, in most parts of the world, it remains taboo and is rarely talked about.
As a result, the practical challenges of menstrual hygiene are made even more difficult by various socio-cultural factors. Potential risks of poor menstrual hygiene management It is assumed that the risk of infection (including sexually transmitted infection) is higher than normal during menstruation because the plug of mucus normally found at the opening of the cervix is dislodged and the cervix opens to allow blood to pass out of the body.
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In addition, the pH of the vagina is less acidic at this time and this makes yeast infections such as Thrush (Candidiasis) more likely. Certain practices are more likely to increase the risk of infection. Using unclean rags, especially if they are inserted into the vagina, can introduce or support the growth of unwanted bacteria that could lead to infection. Some girls and women may roll up sanitary pads and insert these into the vagina. Prolonged use of the same pad will also increase the risk of infection. Douching (forcing liquid into the vagina) upsets the normal balance of yeast in the vagina and makes infection more likely. Wiping from back to front following defecation or urination causes contamination with harmful anal bacteria, such as Escherichia coli (E.coli), which can also be transmitted from the rectum to the urinary tract and/or vagina during sex. The risk of passing on, or in some cases contracting blood-borne diseases (eg HIV or Hepatitis B) through unprotected sex is also increased during menstruation. This is because the highest concentrations of HIV and Hepatitis B are found in blood, with lower concentrations found in other body fluids such as semen and vaginal secretions. These additional risks mean that ensuring good hygiene during menstruation is very important. However, research on the actual risks to health of different menstrual hygiene practices, particularly in low-income countries, is patchy or absent.
Dear Trainees: What is the impact of menstrual hygiene in educational performance of school girls? Discuss your view with others.
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4.2 Hygiene Promotion Hygiene promotion is the planned, systematic attempt enabling people to take action to prevent or mitigate water and sanitation related diseases. It also provides a practical way to facilitate community participation and accountability in every water, sanitation and hygiene. It involves ensuring that optimal use is made of the water, sanitation and hygiene enabling facilities provided. Previous experience shows that facilities are frequently not used in an effective and sustainable manner unless hygiene promotion is carried out. Access to hardware (construction of sanitation facility) combined with an enabling environment and hygiene promotion make for hygiene improvement. Hygiene promotion encourages healthy choices in life, a healthy way of life. It is important to understand what motivates people to make healthy choices and what motivates them to change their behavior. In fact, a desire for good health is often not the primary motivating factor for change. Instead, other factors such as convenience, social status, the esteem of others and financial gain might be the driving forces behind change. Experience has shown that wide-ranging benefits result when communities actively involved in their own health and participate in water and sanitation projects. Using participatory approaches to engage the community has many benefits. Such approaches give community members the opportunity to build and strengthen problem-solving skills and empower them to take action. While communities, initially, might have limited capability to respond, giving them the opportunity to be involved helps with their own recovery process. Through community involvement, water and sanitation programmes and projects can gain a thorough understanding of the needs, concerns and values of the beneficiaries. The local skills and capacities that exist among the disaster-affected population can also be identified and strengthened. Strong community involvement is critical for projects being sustainable long after external assistance stops.
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The following are the main principles of participatory approaches:
Communities can and should determine their own priorities in dealing with the problems that they face;
The enormous depth and breadth of collective experience and knowledge in a community can be built on to bring about change and improvements;
When people understand a problem, they will more readily act to solve it;
People solve their own problems best in a participatory group process.
The Participatory Hygiene and Sanitation Transformation (PHAST) approach is used to promote hygiene sanitation and community management of water and sanitation facilities. The approach encourages people to address and solve their own health-related problems and uses health awareness and understanding as the basis upon which people embrace lasting behavior change toward water, sanitation and hygiene.
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Table 7. Behaviors to be recommended in hygiene education Water source: All children, women, and men in the community should use safe water sources for drinking and food preparation.
Adequate water should be used for hygiene purposes such as bathing, household cleanliness, and clothes washing.
Water should be efficiently used and not wasted. Wastewater should be properly drained away.
Improved water sources should be used hygienically and be well maintained.
There should be no risk of contamination of water sources from nearby latrines, wastewater drainage, cattle, or agricultural chemicals. Water treatment: Simple purification procedures, e.g. chlorination, should be carried out on the water source if necessary.
If necessary, water should be filtered to remove any solid material, guinea worm, etc.
Water collection: Drinking-water should be collected in clean vessels without coming into contact with hands and other materials. Water should be transported in a covered container. Water storage: Water should be stored in vessels that are covered and regularly cleaned.
Drinking-water should be stored in a separate container from other domestic water wherever possible.
Water drinking: Drinking-water should be taken from the storage vessel in such a way that hands, cups, or other objects cannot contaminate the water. Water use: Adequate amounts of water should be available and used for personal and domestic hygiene. Food handling: Hands should be washed with soap or ash before food is prepared or eaten.
Vegetables and fruits should be washed with safe water, and food should be properly covered.
Utensils used for food preparation and cooking should be washed with safe water as soon as possible after use and left in a clean place.
Excreta disposal: All men, women, and children should use latrines at home, at work, and at school.
The stools of infants and young children should be safely disposed of.
Household latrines should be sited in such a way that the pit contents cannot enter water sources or the groundwater table.
Hand-washing facilities and soap or ash should be available, and hands should always be washed after defecation and after helping babies and small children.
Wastewater disposal: Household wastewater should be disposed of or reused properly. Measures should be taken to ensure that wastewater is not allowed to create breeding places for mosquitoes and other disease vectors or to contaminate safe water.
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Why is hygiene promotion (e.g. hand washing) not sustainable? 1. Behavior change is easy Getting people to change the habits of a lifetime is difficult, takes time and requires resources and skill. 2. Knowledge change = behavior change It was thought that education about hygiene would be enough for people to change their behavior. However, many people already know about germs, but still do not wash their hands. Change might be too expensive, time-consuming or there might be discouragement from other members in society. 3. Experts know how to change behavior Hygiene promotion programmes cannot be designed by experts in an office. They have to de designed around the real needs, wants and contexts of the actors themselves i.e. by taking a consumer-centered approach. On the other hand, hygiene promotion programmes cannot be designed by communities themselves. Outside expertise is also needed. 4. A whole variety of hygiene practices should be encouraged Only a limited number of unhygienic practices are likely to be responsible for most diarrheal episodes. Since behavior change is difficult, efforts should not be diluted by targeting too many practices. 5. Hygiene promotion is a cheap add-on to water programmes Serious efforts to change behavior require serious investment and professional skill. Hygiene promotion needs careful planning and the best solutions might, or might not dovetail well with water and sanitation activities.
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4.3 Community Participation and Empowerment Simply providing sufficient water and sanitation facilities will not, on its own, ensure their optimal use or impact on public health. In order to achieve the maximum benefit from a response, it is imperative that people have the necessary information, knowledge and understanding to prevent water and sanitation-related diseases and to mobilize their involvement in the design and maintenance of those facilities. Hygiene behaviours are particularly difficult to change because they relate to daily activities, they are shared by the whole community, and they form part of the culture and traditions of the community. The improvement of water supply, sanitation, and hygiene should be seen as part of an overall process of community development. It is important, therefore, to work with the whole community and particularly with school children, and to involve them in all stages of hygiene education, including selecting priority hygiene behaviours, understanding the influences on such behaviours, selecting educational methods, and implementation. Communities must be equipped with the knowledge and skills to effectively manage their own facilities and to demand highquality
services
from
government,
civil
society
and
the
private
sector.
The educational methods used should be those that strengthen and empower individuals and communities to work for change. There are no set rules for developing a community participation programme, but the stages described in below are common to many such programmes. The community may already be highly organized and taking action on health issues. If so, only a few visits by surveillance field staff will be needed to introduce the concepts of surveillance and involve the community in the surveillance programme. However, it may be that there is no well developed structure, that sections of the community, such as women, are poorly represented, and that there are disagreements or factional conflicts. In this situation, achieving community participation will take more time and require many visits by field staff to bring people together, resolve differences, agree on common aims, and take action. Even after the community starts to become involved, further visits will be needed to provide support and encouragement, and ensure that the structures created continue to operate.
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Table 8. Stages in the community participation process Getting to know the community: •
learning about the community, its structure and leadership pattern
•
initial contacts with families, leaders and community groups
•
dialogue and discussion on concerns and felt needs
Organization building: •
strengthening of community organization
•
establishment of new structures, e.g. water committees, women‟s groups
•
educational activities within community structures
•
decision-making on priorities
•
selection of community members for training as water leaders
Initial actions: •
action by the community on achievable short-term goals that meet felt needs and bring the community together
•
reflection on initial activities
•
setting of priorities for future activities
Further actions: •
activities in which the community takes a greater share of responsibility for decision making and management
Factors influencing hygiene behavior and selection of content of education Hygiene education programmes should be based on an understanding of the factors that influence behavior at the community level. These might include:
enabling factors such as money, materials, and time to carry out the behavior;
pressure from particular members of the family and community, e.g. elders, traditional healers, opinion leaders;
beliefs and attitudes among community members with respect to the hygiene behavior, and especially the perceived benefits and disadvantages of taking action, and the understanding of the relationship between health and hygiene.
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An understanding of the factors that influence hygiene behaviours will help in identifying the resources (e.g. soap, storage containers), the key individuals in the home and community, and the important beliefs that should be taken into account. Before a formal hygiene education programme is begun, it is important to include in the sanitary survey an assessment of the socio-cultural factors that characterize the community, in order to determine: local beliefs and attitudes regarding water, sanitation, and health; traditional water use and defecation habits and excreta disposal practices; current levels of knowledge about disease transmission, especially among community leaders and other influential individuals; the priority given to improvements in water supply and sanitation in relation to other community needs; existing channels of communication in the community including books, newspapers, and magazines, radio or television, traditional drama, songs, and story-telling; the members of the community and field workers from other agencies who might be involved in hygiene education activities.
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Table 9. Characteristics of effective health education • Promotes actions that are realistic and feasible within the constraints faced by the community •
Builds on ideas and concepts that people already have and on common practices
•
Is repeated and reinforced over time using different methods
•
Uses existing channels of communication, e.g. songs, drama, and story-telling, and can be appropriately adapted to these media
•
Is entertaining and attracts the community‟s attention
•
Uses clear simple language and local expressions, and emphasizes the short-term benefits of action
•
Provides opportunities for dialogue and discussion to allow learner participation and feedback
•
Uses demonstrations to show the benefits of adopting the practices recommended
Methods of communicating health promotion messages Places for communicating messages:
House to house visit (at household level)
At village level
At schools
At health institutions
At religious or places of worship (churches and mosques)
At traditional meeting places (Edir)
At market places
At development offices.
Methods of communicating messages:
Person to person (discussion)
Calling a meeting (for large group)
Group meetings
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Using demonstration method
Using drama, songs, poems, story telling
Using exhibition
Transmitting short acts at holidays.
Using tape recorder.
Using posters, pamphlets and brochures.
Using public mass media e.g. radio, television etc.
Using health education films
In hygiene education, it is important to emphasize participatory learning methods; these can include small-group teaching, simulations, case studies, group exercises, and role play. These methods: avoid formal lecture presentations encourage discussion between participants encourage interaction during the sessions use a variety of games, puzzles, and exercises use learning aids that stimulate discussion and comments.
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Table 10. Potential human resources for hygiene education in the community Health services:
Agricultural and development workers:
Doctors and nurses in primary health care
Agricultural extension workers
Midwives
Community development workers
Health visitors
Cooperative workers
Public health nurses
Women‟s programme staff
Medical assistants
Education services:
Nutrition programmes
Teachers in primary and secondary schools
Immunization programmes
Adult education staff
Special disease programmes
Literacy programme staff
Health extension workers
Preschool programme staff
Environmental health /sanitary technicians
Vocational trainers
Veterinarians
Informal resources in the community:
Public health services:
Elders
environmental health inspectors
Parents
Water supply staff
Traditional birth attendants
Sanitary technicians
Traditional healers
Refuse management staff
Village leaders
Environmental/sanitary engineers
Religious leaders
Is hygiene education in your catchment area conducted in an integrated and coordinated manner among the sectors?
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Case Study 1: Senait, Meselu and Zenebu are Health extension agents working in one woreda to execute WASH and other health packages. A task was given to them to construct 100% coverage of latrine in the assigned kebele. This is because it has political importance and the government officials impose them to force the community as they will not get any other service from government if they do not dig and construct simple pit in their house. The whole kebele constructed a latrine without being willing and that particular kebele was selected as model kebele and declared 100 % coverage of latrine facility. Hand washing facility is near the latrine but, they are not using after the kebele has celebrated the occasion of latrine graduation. In the nearby health center, there is high prevalence record of communicable diseases like diarrheal diseases (typhoid, amoebiasis, shigellosis, cholera and others) and trachoma. 1. Why are the diseases occurred? 2. What are the problems observed from the health extension agents and officials? 3. What should be the solution for the problems? 4. Do you have any experience related to the story, please share the experience to others?
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Case Study 2. There was a deep rooted problem of water supply in one Kebele. The communities were suffering with water supply shortage and water washed disease due to lack of water for drinking, hygiene and sanitation. An International Non Governmental Organization (INGO) has decided to develop a water supply to the community by digging a well without consulting the community. The INGO finally inaugurates the project and gave for the community to use as a potential source of water supply. Unfortunately, the community refused to use the water supply as their drinking water source. The INGO surprised and ask them why you do not use the developed water since we invest huge amount of money for the sake of you. The community replied "we will not drink the blood of our forefathers" because it was constructed near to the local burial place. Based on the story 1. What critical gaps you observed among the community and INGO? 2. What type of approach should the INGO fellow to overcome suck kind unforeseen problem? 3. Is there any other similar story you observed during your work?
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UNIT FIVE: REGIONAL CONTEXT PROBLEMS AND RECOMMENDED SOLUTIONS Major Challenges In 2006 E.C(2013/14 G.C) at National Level Many hygiene and environmental health activities were carried out in EFY 2006. With this regard to open defecation free (ODF) kebeles , a total of 3,655 kebeles were declared as ODF kebeles in Ethiopian Fiscal Year (EFY) 2006. Besides the ODF verification team was established to assess ODF kebeles. Challenges About Environmental Health activates of the year 2006 E.C (HSDP IV,2013/14) Inadequate number of environmental health professionals at all levels Absence of regular and integrated monitoring and evaluation activities Inadequate implementation of the hygiene and environmental health package in HEP Limited ownership on OWNP and sanitation projects by some regions Limited attention on urban sanitation Inadequate capacity to scale up best practices and uncoordinated support from partners Ways forward Recruit environmental health professionals at all levels ensure integrated Monitoring and evaluation activities Improve the implementation of hygiene and environmental health package strengthen the capacity of regions on the ownership of ONWP and sanitation projects give attention to urban sanitation strengthen the capacity of regions to scale up best practices and strengthen harmonization and alignment according to "One-plan, one- budget, and One report" principle
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Tigray Region Ethiopian Institute of Water Resources, Addis Ababa University in Collaboration with Mekelle University has deployed undergraduate students for summer outreach work in Degua Temben to assess the community problems especially related with water, sanitation and hygiene. We hope you have the full report of the outreach undergraduate students. According to their survey result the major finding were:
Lack of community awareness on the importance of WASH
Lack of sanitation infrastructure 32% of the households have no latrine
General Environmental Sanitation problems
Lack of coordination and integration among different stakeholders
Peoples are forced to construct sanitation facility like latrine because of its political importance not health importance as it is one means of evaluation the effectiveness of the political leaders
Unfair and unsustainable distribution of sanitation facilities like slabs
General economic problems
Gender bias, assuming as women are the only responsible for WaSH related activities
Common problems of diseases like diarrheal diseases which are directly and indirectly linked with poor hygiene and sanitation
Lack follow up (monitoring and evaluation) for WaSH and related activities
Based on the identified critical problems the possible solutions should be: There should be continuous awareness of the community about the health importance of water, sanitation and hygiene There should be coordination among sectors. All governmental sector who have a common interest in WaSH should work together for a common out put
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The community should empower to construct sanitation facility with their own material for better sustainability. subsidy of sanitation facility should be not promoted as it will create a sense of dependency on the donors The implementation of every WaSH facility should be in line with health importance. if there is another force that will interfere out of the professionals goal its desired output ends fruit less. Therefore, the implementation of WaSH should not be because of the community are politically forced to construct but, they should understand its importance Men should be equally share the responsibility of women as it will create a gender bias and women develop a sense of inferiority as they are only responsible to fetch water, collect fire wood and solve the WaSH related problems in their family There should be close discussion among community, health professional and politicians on WaSH issues There should be refreshment and periodic training for: Health Extension workers Community Politicians and Administrators There should be practice sanitation marketing if the community do not have durable and locally available construction material. But, the there should not a free supply of sanitation facility There should be regular follow up (monitoring and evaluation) on the progress of the activities
Dear participants! What other experience do you have on the cases raised above? please share your experience for others.
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Amhara Region Ethiopian Institute of Water Resources, Addis Ababa University in Collaboration with Bahirdar University has deployed undergraduate students for summer outreach work in Mecha woreda to assess the community problems especially related with water, sanitation and hygiene. We hope you have the full report of the outreach undergraduate students. According to their survey result the major finding were:
There is awareness gap about WaSH
Most of the community are practicing open defecation they are not using the latrine properly due to negligence, some of them are not durable and they easily demolished
Females need training as they are the most responsible for almost all household activities like water handling, food preparation, feeding of infants on the general water handling, hygiene and sanitation
Common problems of diseases like diarrheal diseases which are directly and indirectly linked with poor hygiene and sanitation
Lack of coordination among different stakeholders
Water fetching was assumed as it is the sole responsibility of females which has negative influence on the educational performance of school girls
People construct toilet due to fear of punishment not because they are willing to construct
Majority of the community sleep together with animals during night time
There is no separate kitchen
There is lack monitoring and evaluation about the activities Based on the identified critical problems the possible solutions should be: There should be continuous awareness of the community about the health importance of water, sanitation and hygiene There should be integration of different stakeholders for better achievement of the program
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The community should empower to construct and properly use sanitation facility with their own material for better sustainability. subsidy of sanitation facility should be not promoted as it will create a sense of dependency on the donors. It should not be due to fear of punishment that the community are constructing latrine but, for the sake of improving their health as it deprives its proper use and sustainability Men should be equally share the responsibility of women as it will create a gender bias and women develop a sense of inferiority as they are only responsible to fetch water, collect fire wood and solve the WaSH related problems in their family There should be close discussion among community, health professional and politicians on WaSH issues There should be refreshment and periodic training for: Health Extension workers Community Politicians and Administrators There should separate living room for animal There should be a separate kitchen There should be practice sanitation marketing if the community do not have durable and locally available construction material. But, the there should not a free supply of sanitation facility There should be regular follow up (monitoring and evaluation) on the progress of the activities
Dear participants! What other experience do you have on the cases raised above? please share your experience for others.
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Oromia Region Ethiopian Institute of Water Resources, Addis Ababa University has deployed undergraduate students for summer outreach work in Sheno woreda to assess the community problems especially related with water, sanitation and hygiene. We hope you have the full report of the outreach undergraduate students. Some of the major identified problems were: Poor environmental sanitation Lack of awareness about the importance of WaSH Low economic status Flooding problems lack of space for sanitation facility construction in slum areas Females are only considered the responsible body for all WaSH activities like fetching water Common problems of diseases like diarrheal diseases which are directly and indirectly linked with poor hygiene and sanitation There is low coverage of latrine and those who have do not use properly Low health dissemination for community from professionals Lack of integration and cooperation among all stake holders Lack follow up (monitoring and evaluation) for WaSH and related activities Based on the identified critical problems the possible solutions should be: There should be continuous awareness of the community about the health importance of water, sanitation and hygiene There should be integration of different stakeholders for better achievement of the program 86 | P a g e
There should be diversion ditch to protect flooding Men should be equally share the responsibility of women as it will create a gender bias and women develop a sense of inferiority as they are only responsible to fetch water, collect fire wood and solve the WaSH related problems in their family There should be close discussion among community, health professional and politicians on WaSH issues There should be refreshment and periodic training for: Health Extension workers Community Politicians and Administrators There should be construction of communal latrine for those who do not have adequate space for construction The community should empower to construct their own latrine especially those who lacks an awareness There should be regular follow up (monitoring and evaluation) on the progress of the activities
Dear participants! What other experience do you have on the cases raised above? please share your experience for others.
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Southern Nation, Nationalities and Peoples Region Ethiopian Institute of Water Resources, Addis Ababa University in Collaboration with Hawassa University and Arbaminch University has deployed undergraduate students for summer outreach work in Tula and Mirab Abaya to assess the community problems especially related with water, sanitation and hygiene. We hope you have the full report of the outreach
undergraduate
students. The effectiveness of WASH intervention can be judged based on the ten top diseases in the catchment area. Table 11. Five leading causes of under 5 years morbidity in Sidam Zone, Southern Peoples Nations and Nationalities Region, 2014. S/N
Woreda
1 2 3 4
Pneumonia Malaria (All species, P.F and P.V) Diarrhea (non-bloody) Infections of the skin and subcutaneous tissue Acute upper respiratory infections
5 Total
M 0-4 years 15,909
F 0-4 years 12240
8367 3286
6108 1314
3252
2493
Total
%
28,149 15806 14475
40.9 23.0 21.0
4600 5745 68,775
6.7 8.4 100.0
Table 12: Top ten leading cases of above 5 years Morbidity in Sidama Zone, Southern Peoples Nations and Nationalities Region, 2014 S/N
Woreda
1 2 3 4 5 6 7 8 9 10 Total
Malaria all species Acute febrile illness (AFI) Helminthiasis Urinary tract infection Typhoid fever (AFI) Trauma, (injury, fracture etc) Pneumonia Dyspepsia Other infectious and parasitic diseases Acute upper respiratory infections
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M >5 years 18072 17140 15479 14935 19518 12929 5716 7271 6823
F >5 years 19156 19,453 19,069 17520 9076 12714 10429 7574 7138
Total 70607 37228 36,593 34,548 32455 28594 25643 16145 14845 13961 310,619
% 22.7 12 11.8 11.1 10.4 9.2 8.3 5.2 4.8 4.5 100.0
Table 13. Top 10 causes of morbidity in Arba Minch Zuria woreda, (in all age groups at Inpatient Department & Out Patient Department level), 2006 E.C No. 1 2 3 4 5 6 7 8 9 10
Description Diarhea (non-bloody) All respiratory diseases Acute febrile illness Pneumonia Infections of skin and subcutaneous tissue Malaria all types Trauma (injury, fracture etc.) Helmentiasis Pneumonia Diarhea with blood (dysentery)
male 1112 1137 1031 840 701
female 1,055 916 833 604 287
total 2,167 2,053 1,864 1,444 988
% 26.4 15.5 14.1 10.9 7.5
600 488 351 331 165
352 260 362 228 126
952 748 713 559 291
7.2 5.7 5.4 4.2 2.2
Total of the above causes Total of the other causes Total of the all causes
6,756 790 7,546
5,023 643 5,666
11,779 1,433 13,212
89.2 10.2 100%
Dear participants please discuss the diseases associated with WASH and level of WASH intervention in your locality?
Some of the major identified problems from the undergraduate WASH survey were: Poor environmental sanitation Only 53.1% have toilet of which 74% are not as per the standard Lack of awareness about the importance of WaSH Lack of durable construction material and most latrines were with no superstructure Risk of flooding problems Females are only considered the responsible body for all WaSH activities like fetching water and they are not recognized their contribution in WaSH intervention 89 | P a g e
Low number of health extension workers Common problems of diseases like diarrheal diseases which are directly and indirectly linked with poor hygiene and sanitation Low health dissemination for community from professionals Lack of integration and cooperation among all stake holders Lack follow up (monitoring and evaluation) for WaSH and related activities Based on the identified critical problems the possible solutions should be: There should be continuous awareness of the community about the health importance of water, sanitation and hygiene There should be integration of different stakeholders for better achievement of the program There should be diversion ditch to protect flooding Men should be equally share the responsibility of women as it will create a gender bias and women develop a sense of inferiority as they are only responsible to fetch water, collect fire wood and solve the WaSH related problems in their family Women's contribution for WaSH should be recognized and appreciated There should be close discussion among community, health professional and politicians on WaSH issues There should be refreshment and periodic training for: Health Extension workers Community Politicians and Administrators The community should be empowered to construct their own latrine especially those who lacks an awareness There should be regular follow up (monitoring and evaluation) on the progress of the activities Dear participants! other experience do you have on the cases raised above? please share your experience 90 | P a g What e for others.
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Training Initiative, the Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education, Addis Ababa, Ethiopia. 19. MoFED (2010). Growth and Transformation Plan (2010/11-2014/15). Volume I.
Ethiopian Ministry of Finance and Economic Development (MoFED), Addis Ababa, Ethiopia. 20. MoH (2004). Water Supply Safety Measures. Health Extension Package. Federal Democratic Republic of Ethiopia Ministry of Health (MoH), Addis Ababa, Ethiopia.
21.MoH (2013/14). HSDP IV Report of Fiscal year 2006 E.C 22. Tebbutt, T.H.Y. (1998). Principles of Water Quality Control. 5th Edition. ButterworthHeinemann Publisher, Oxford. 23. WHO (2013). Household Water Treatment and Safe Storage: Manual for the Participant. World Health Organization, World Health Organization Regional Office for the Western Pacific. 24. WHO (2011). Guidelines for Drinking Water Quality. 4th Edition. World Health Organization (WHO), Geneva. Switzerland. 25. WHO (1997). Guidelines for drinking-water quality. Volume 3. Surveillance and control of community supplies. 2nd Edition. World Health Organization. Geneva. 26. WHO and UNICEF (2000). Global Water Supply and Sanitation Assessment 2000 Report. World Health Organization/UNICEF, Geneva/New York. 27. WaterAid (2012). Menstrual hygiene matters a resource for improving menstrual hygiene around the world. 28. WHO and UNICEF (2014). Progress on Drinking Water and Sanitation an 2014 Update.
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