Kap Report Endline September 2012

KNOWLEDGE ATTITUDES AND PRACTICES (KAP) END-LINE ASSESSMENT On Water, Sanitation and Hygiene LOLKUACH Village, IDPs of Akobo September-2012 DRC-Gambella WASH Team Conducted in the frame of an ECHO funded project â€Å"Improving access to short-term food security, safe drinking water, hygiene and basic household items in Ethiopia† Wanthowa Worda, Gambella, Ethiopia September 30, 2012 i TABLE OF CONTENTS 1 2 3 3. 1 INTRODUCTION SUMMARY OF FINDINGS METHODOLOGY Objectives of the Survey 1 2 3 3 4 4. 1 FINDINGS General Background Information 4 4 5 5. 1 5. 2 5. 3 WATER RELATED INFORMATIONWater Sources Water collection and storage Household Water Treatment 5 5 9 11 6 6. 1 6. 2 HEALTH AND HYGIENE Diseases Washing Hands and Good Hygienic Practices 12 12 15 7 7. 1 7. 2 SANITATION Defecation Waste and Waste Management 18 18 20 8 9 CONCLUSION RECOMMENDATIONS 23 24 25 10 REFERENCES i 1 Introduction The 2012 report states that as of end of 2010: Over 780 million people are still without acce ss to improved sources of drinking water and 2. 5 billion lack improved sanitation. If current trends continue, these numbers will remain unacceptably high in 2015: 605 million people will be without an improved drinking water source and 2. billion people will lack access to improved sanitation facilities. An estimated 801,000 children younger than 5 years of age perish from diarrhea each year, mostly in developing countries. This amounts to 11% of the 7. 6 million deaths of children under the age of five and means that about 2,200 children are dying every day as a result of diarrheal diseases. Unsafe drinking water, inadequate availability of water for hygiene, and lack of access to sanitation together contribute to about 88% of deaths from diarrheal diseases (UNICEF, WHO, 2012: 2; Center of Disease Control and Prevention, 2012).As to Andrea Naylor: although worldwide there have been thousands of projects to address water and sanitation issues as they relate to public health with c ontinued improvements since the 1980’s, research has shown that due to lack of evaluation surveys on the effectiveness and success of these interventions, many are not sustainable . To this end, the essence of conducting end-line survey is very critical to gauge the effectiveness and success of the interventions of DRC-Gambella. The Gambella Region has an approximately population of 332,600 people, with 49,457 living in Akobo and Wantawo Woredas.These populations are subjected to water shortage and floods. Moreover the population is prevalently pastoralist and follows seasonal migration patterns for cattle grazing and protection of livestock from drought and floods. The perennial attacks by the Murle tribe, coupled with intra-clan conflicts among the Nuer tribes of Ethiopia and South Sudan, aggravates a situation of chronic displacement, making populations of bordering areas, especially Akobo, susceptible of massive and prolonged internal displacements.Conflicts, drought and floods are the key challenges to the populations in Akobo and in Wantawo. The consequent perennial movement makes the community vulnerable to food insecurity, disease and water shortage. It is in view of this that Danish Refugee Council seeks to address in the short term the basic needs of these populations by providing access to clean drinking water, and tools to improve hygiene and to build the capacity of the community to respond to these challenges. From the period of July 2011 to June 2012, DRC implemented a Water, Sanitation and Hygiene project, funded by ECHO, with the goal of rehabilitating 7 hand pumps (and subsequently chlorinating the water), distributing NFI kits, hygiene kits, and implementing hygiene promotions. DRC decided to conduct two in-depth KAP surveys (as a baseline and endline) to evaluate the impact brought by the implementation of the project in the targeted area.The baseline survey was conducted in the month of May 2012 and the end line survey was conducted in the second week of September 2012. In the period between the two surveys, a number of activities covering water, sanitation and hygiene were implemented in the frame of the project. 2 Summary of Findings Project outputs and behaviour and knowledge change (as indicated by the pre and post implementation KAP surveys) indicate the following key findings: o o o o o o Seven hand pumps were rehabilitated/ disinfected Hygiene promotion targets were surpassed. planned: 5,490 beneficiaries; 10,950 reached) Hygiene kit distributions were surpassed (planned: 2,250 beneficiaries; 8,870 reached) NFI kit distributions were surpassed (planned 6,300 beneficiaries; 7,470 reached) The number of respondents who use hand pumps as source of water increased from 4% to 75% Knowledge and practice of feasible water purification practices such as boiling, filtration or adding tablet/sachet has been greatly improved Instance of diarrhoea has decreased from 60% to 24% of respondents stating that they had h ad diarrhea in during the 3 weeks prior to the survey Knowledge that rain water is a safe drinking water source has improved from 24% to 62% of respondents, however, the use of rain water remains limited.Knowledge of the causes of unsafe drinking water (including germs, visible particles and bad taste) increased from 40% to 81%. The practice of open defecation has reduced from 100% to 15% of respondents. Hand washing at critical times has increased from 34% to 85% of respondents. 2 o o o o o o o Appropriate waste disposal mechanisms improved from 39. 2% in baseline to 75% of respondents.. Although there has been an improvement in the knowledge of respiratory and eye infection transmission/protection, there is still room for improvement 3 Methodology A cross sectional, qualitative study was conducted through house to house interviews, taking 150 respondents randomly as study subjects. The sample represents nearly 10% of the total targeted household 1 n Lolkuach village (1,500 househo ld). The questionnaire (See Annex I) was employed to collect data on general background information, knowledge, attitude and practices of the IDPs of Lolkuach village. However the results can also be considered pertinent for the host communities if considering the cultural and environmental homogeneity. Verbal consent from the respondents was obtained after explaining the purpose of the study. Data was collected from 13 to 14 September 2012. The data from the questionnaires was entered into SPSS software (version 13) by the principal investigators for further analysis. Data reliability was assured using different techniques such as: ?Properly designed questionnaires were prepared and pretested. ? Data collectors were hired locally and tested during the training on the contents of the questionnaire. Constant supervision was done by DRC WASH Team Leader, and problems encountered at the time of data collection were reported immediately and appropriate actions taken. 3. 1 Objectives of the Survey ? To identify gaps in knowledge regarding health and hygiene practices and existing practices leading to negative impact on health. ? ? To describe the socio demographic, cultural information of respondents and villages. To find out the information on incidence of communicable disease due to unhygienic practice. 1It is estimated, on the base of IOM Akobo IDPs database, that the number of households currently living in Lolkuach is 1500 and average family size is 5. 3 ? To assess the effectiveness and impact of the DRC water, sanitation and hygiene promotion activities. 4 Findings 4. 1 General Background Information The beneficiaries of the programme, and KAP survey respondents are all part of the displaced NuerGajok population from Akobo Woreda now living in Wantawo. Among the KAP survey respondents, the majority (about 65 %) were female, whereas 35% were male. Females were particularly targeted for the KAP survey, as they were the primary recipients/participants in the DR C project, and are traditionally responsible for child care and household WASH issues.This survey was conducted near the end of the rainy season, in Lolkuach IDP settlement. Respondents reported moving between the river banks temporary camps and dry land permanent villages according to seasonal variations. During the dry season, the majority of the respondents live in Dimbierow village (79%), and Nyawich village (17%), while only 4 % of the respondents indicated that they live in Lolkuach village throughout all the year. However there are frequent movements among the settlements throughout all the year. Most of the respondents (86. 2%) indicated that they arrived at Lolkuach between February and June 2009 following a recurrence of conflict with Lou Nuer in Akobo woreda.Minority of the respondents arrived during the same period of 2008 (12. 8%) or 2010 (1 %). Most of the respondents therefore have been displaced since 2009. When respondents were asked if they plan to return to their villages of origin, a pronounced number (55%) indicated that they don’t have any plans to return due to security problems (expressed as ‘war’, ‘conflict’, ‘insecurity’). The remaining 45% of the respondents indicated that they plan to return back in the future if the security situation is restored and the construction of the road from Mathar to Akobo is finalized. In this regard, as it can be observed from the baseline survey, no significant difference noted in the end line survey.However looking in detail at the positive answers (from the 45% of respondents), 21% expressed a plan to go back within six months and the remaining 34% indicated a time longer than six months. Moreover even the respondents who indicated that they have a plan to return back to 4 Kebele of origin also mentioned their fear about the security situation (expressed as ‘if peace come back’, ‘if cattle raiding ends’, if the construction of th e road to Akobo is completed and similar). 5 Water Related Information 5. 1 Water Sources Before the project interventions, the baseline data indicated that almost 100% of the respondents were accessing unsafe drinking water from the river, which is contaminated from the presence of livestock and open defecation. At the end of the project implementation, the hand pump aintenance/rehabilitation/water chlorination, coupled with pure sachet distributions, bucket distributions, and hygiene promotions resulted in a significant positive change. As you can observe from the Figure 1, the majority of the respondents are now using water from newly maintained/rehabilitated hand pumps. Due to seasonal movement however, the proportion of respondents using hand pumps during the dry season reduces, as many of the beneficiaries move to areas without hand pumps. The following graph outlines both the shift in hand pump use (pre and post intervention), and also the relation of this use in terms of sea sons. There are still not sufficient hand pumps in Lolkuach area to support the population however, which explains why 100% of the respondents are not using these protected sources.Considering that the 7500 inhabitants of Lolkuach, Thore and Lolmokoney have only 7 hand-pumps (hand dug wells), this is insufficient as per SPHERE standards)2 , highlighting the need to construct new hand pumps. 2 Considering the maximum number of users for 1 hand pump should be 500, at least 15 hand pumps would be needed in Lolkuach 5 Seasonal Use of Protected Water Sources – Pre and Post Intervention 100 90 80 70 60 50 40 30 20 10 0 Dry Season Rainy Season % of Respondents Seasons Baseline Endline Figure 1: Shift in Use of Protected Water Sources (KAP baseline an d end-line) Seven hand pumps in Lolkuach and surrounding villages were disinfected and beneficiaries received pure sachet as well bucket and filter.From the findings, the graph below states that it is only 27% of the respondents indicat ed that the main problems with their water source are water is dirty and it tastes bad. Whereas 40. 7% of the respondents also signified that the water source is far. Problems Related to Water Supply 100 90 80 70 60 50 40 30 20 10 0 Dirty Water Bad Taste Irregular FlowSource is Dried Distance to No problems Up Source % Respondents Baseline Endline Water Source Issues Figure 2: Main problems related to water supply. 6 Consequently 63% of the respondents consider the water they are using is safe for drinking, and 33% consider it is unsafe instead (Figure 3).This represents a reduction in the proportion of respondents who stated that they were using unsafe water from 77% in the baseline to 33% in the end-line survey. Of these 33% of respondents who noted that they were drinking unsafe water, 8% of the respondents were using hand dug wells (Which were rehabilitated by DRC) as source of water for drinking. Figure 3: consideration of water safety Figure 4: reasons why 33% declared water i s unsafe In relation to the safety of water, the reason why 33% of respondents declared that they are using unsafe water is mainly because the water contains germs, is not filtered and not cleaned. This shows that their understanding about the causes of unsafe water has improved since the baseline (Figure 4).When it comes to use of rainwater as source, though improvement is registered, much needs to be done to bring about significant change. Considering the shortage of safe water sources in the area observed by DRC, and the abundant rain-fall in Gambella region3, reasons for not using the rainwater (which is almost distilled4) were assessed more closely. Although the number of respondents who believe that 3 The annual rain falls in Gambella region ranges between 800 and 1200mm, but about 85% of rains are concentrated between May-October (Woube, 1999). 4 In this regards, Dev Sehgal, indicated that rainwater harvesting is an easy method to collect drinking water, and the quality of th e water is almost distilled.First when the water touches the catchment surface it usually gets contaminated (Dev Sehgal, 2005). 7 rainwater is unsafe has reduced from 76% to 38% of respondents, more can be done to raise awareness on this water collection method. Of the 38% of respondents who would not collect rain water given the choice, the principal reasons were given as follows: Figure 5: Investigation about unused rain water When questioned on their knowledge of safe drinking water and water pollution causes, respondents were given the option of providing more than one answer. The number of respondents who indicated that drinking water shouldn’t have germs, visible particles and/or bad taste, increased from 40% at the baseline to 81. 3% at the end-line.The respondents who indicated that the proximity of a latrine to water sources can cause water contamination increased from 7. 2% in the baseline to 15% in the end-line survey. In this regards, water quality and health coun cil indicated that especially the proximity of latrine to water sources can cause Removing the first harvested water, so-called first flush, can prevent this. When the rain starts to fall the first water cleans the catchment surface and fills up the first flush diverter, by the time it is full a ball closes the opening and leads the water to the main tank. The downside of rainwater harvesting is that it requires double storage, as it is hard to purify water at the same speed as it rains (Gould, J. & Nissen-Petersen, E. , 2005). 8 contamination .The majority of the respondents (85%) also indicated that garbage disposal or animals feces containers near a water source, or unprotected source can cause water contamination (Figure7). 5 Knowledge of Causes of Water Source Pollution 100 90 80 % Respondents 70 60 50 40 30 20 10 0 Defecation Nearby Garbage Nearby Dirty Container Causes of Pollution Figure 7: Knowledge of Water Source Pollutants Baseline Endline Although only a small proportio n of respondents acknowledge that water can be contaminated through the ground from a latrine constructed too close to a water source, 95% of respondents are now aware that defecation near a water source is a pollutant, resulting in a change of behavior in which open defecation has reduced from 100% in the baseline to 15% in the end-line survey. 5. 2 Water collection and storageFrom the Figure 8, it can be observed that nearly 50% of respondents less than 50 minutes to fetch water during dry seasons6, meaning that SPHERE standards for these respondents are met for watersource distance because of the rehabilitations of the hand pump in the vicinity of the village. Concerning rainy season, it can be observed that respondents spend more time getting water. As it is observed, respondents need to travel some distance to fetch water and during the dry season respondents also move to river banks. Hence, this can make the access to hand pump difficult. So besides constructing 5 The causes o f water pollution vary and may be both natural and anthropogenic.However, the most common causes of domestic water pollutions includes : garbage disposal and defecation near water sources, animals feces, sharing the same sources with animals, use of dirty or open water container can affect the safety of our water . Use (Water Quality and Health Councils, 2010; CAWST, 2009; Laurent, P. , 2005). 6 According to SPHERE key indicators, the maximum distance from any household to the nearest water point is 500 metres 9 new hand pumps, encouraging the community for rain water catchment strategy is very essential at household at household level. 70 60 50 40 30 20 10 0 0-50 50-100 Min 100-250 Min More than 250 Dry Season Rainy SeasonFigure 8: Average time spent to collect water Given that water collection requires women and girls to walk distances to find water sources, there may be heightened protection issues for these family members, although protection was not assessed in the KAP. Questio n posed to respondents on what devices that they are using to store and collect water indicated that 55% of the respondents are using plastic jerry cans to collect water and 34% of the respondents use plastic bucket for water collection. For storing water, nearly 33% of the respondents use traditional clay pot and plastic jerry cans; the rest 36% of the respondents indicated plastic jerry cans or buckets with lid.DRC distributed NFI (Contains 2 Jerry cans each 20 litters among others) and Hygiene kits (Contains 2 Buckets each 10 litters among other) to 302 and 283 households respectively living in Lolkuach areas. To this end, most of the respondents own more than one container. But still those who didn’t receive water storage and collection device also were among the respondents who took part in the survey, we can 10 observe that 70% of respondents meet the minimum SPHERE7 requirement for water collection container, and 74% meet the requirement8 for water storage. Whereas in the baseline, it was noted that only 50% of the respondents met the requirement for water storage and collection devices. 5. 3 Household Water TreatmentThe knowledge of practical purification methods like boiling, filtration or adding tablet/sachet was assessed. As it can be observed from Figure 12, there is great leap in knowledge of the basic methods of household water treatment. For instance, use of purifying sachet/tablet increased from 8% at baseline to 85% at the end-line survey. The findings also suggested that the majority of the respondents (more than 75%) know the use of feasible practices like boiling, filtration or adding tablets/sachet for water treatments9. This figure was only 25% in the baseline survey. After the baseline survey, it is worth to note that DRC-Gambella has been distributing purifying sachet and providing demonstrations for those villages with no access to hand pumps. 7According to SPHERE key indicator: Each household has at least two clean water collec ting containers of 10-20 litres, plus enough clean water storage containers to ensure there is always water in the household. The amount of storage capacity required depends on the size of the household and the consistency of water availability e. g. approximately 4 litres per person would be appropriate for situations where there is a constant daily supply 8 Requirement for storage is calculated according to certain specificities, but considering the minimum of 4lt/person/day, for an average household of 5, should be at least 20 lt. 9 Different researchers suggested some feasible practices like boiling, filtration or adding Figuret/sachet and chlorination for water treatment (CAWST, 2009; Davis & Lambert, 2002). 11Knowledge of Household Water Treatment 140 120 % Respondents 100 80 60 40 20 0 special container Boiling Use of sachet Cleaning Filtering container with cloth Covering sunlight Baseline Endline Figure 12: Knowledge of household water treatment methods 6 Health and Hygiene 6. 1 Diseases Respondents were asked about the diseases their family experienced during the three weeks before the interview. The number of respondents who caught diarrhea in the three weeks prior to the interview reduced from 60% in the baseline to 27. 3% in the end-line survey. Hence, you can see from the end-line survey that hygiene conditions and practices are improving.When it comes to the causes of diarrhoea, more than 85% of the respondents referenced unsafe drinking water, children feces, germs/bacteria, open defecation, poor hygienic practices and flies as causes of diarrhea (Figure 16), indicating that the hygiene promotion has resulted in an increase in knowledge. 12 Figure 16: Knowledge about diarrhea transmission Interviewees were asked to indicate in a multiple choice question, which action to be taken to protect their families from the different diseases that they suffered from. The respondents who indicated that they can be protected from malaria by sleeping under m osquito net increased from 40% to 75%. Keeping the environment clean and good hygienic practices also attributed as a method of prevention of malaria by many respondents (Figure 14). 13 Knowldge of Malaria prevetion measure 120 100 Respondents 80 60 40 20 0 Keeping environment Clean Safe water Good hygienic practice Use mosquitonet Wash cloth Wash hand Baseline Endline Figure 14: knowledge of malaria prevention measures When it comes to skin diseases, most of the respondents indicated that good hygienic practice as way of prevention of skin diseases (Figure 15). 14 Figure 15: Knowledge of skin diseases prevention measur es Nearly 51. 2% of the respondents indicated that good personal hygiene, keeping the environment clean, use of safe water for drinking, washing hands, washing clothes and hanging them in the sun can protect their families from respiratory and eye problems.The above results indicate that the knowledge of the people has improved with regards to respiratory illness and eye infection transmission and protection, however there is still room for improvement. 6. 2 Washing Hands and Good Hygienic Practices General question about hygiene and more specific ones about hand washing were posed. Keeping food away from flies, bathing regularly, keeping compounds clean, protecting food and washing hands are considered as good hygienic practices by the majority of the respondents in the end-line survey. This means that the figure increased from nearly 51% at the baseline to nearly 85% in the endline. 15 Figure 18: Knowledge about keeping good hygieneLikewise, when respondents specifically asked if they wash their hands, 89% of the interviewees gave affirmative answer in the end-line Survey. People who wash hands reported to be doing it in order to eliminate bad smell and prevent diseases. Similarly more details of the hand washing practice can be seen from Figure 20, and it can be concluded that more than three fourth of the population who wash their hands, ar e doing it at the appropriate times. 16 Figure 20: Frequency of hand washing practice While the vast majority of the respondents (95%) stated they would like to bathe once a day, when it comes to practice, 29% of respondents expressed they have problems in taking bath regularly mainly because of lack of container and soap (Figure 21).Hygiene practices were also considered to be a major issue by nearly 40. 6% of the respondents, these respondents indicated that poor practices are due to both a lack of access to hygiene items, and a poor attitude brought on by a lack of knowledge. So the majority of the respondents signified that the distributed hygiene kits solved some of their problems and they were adhering to good hygienic practices. 17 7 Sanitation 7. 1 Defecation Before the DRC intervention, the majority of the adults practiced open defecation. Because changing habits is not easy, the baseline assessment was designed to understand the risk practices that were most widespread and identify those that could be changed.From the point of view of controlling diarrhoea, the priorities for hygiene behavioral change included hand washing at critical times and safe stool disposal. To this end, the efforts of the organization brought significant behavioral change. From the end-line survey it is noted that 85% of the respondents use traditional latrines, which is up from 0%. Similarly, when asked to indicate the best option for defecation, 85% indicated the latrine. On the other hand, privacy, water pollution, presence of bad smell and flies, as well as spread of disease was reported as the main problem related to open defecation practices (Figure 23). Respondents were also asked about post defecation cleansing habits and mostly indicated pieces of paper. Figure 23: Problems related to defecation practice 18Considering the majority of respondents indicated that a latrine is the best option for defecation, and that the main issue with defecation is privacy, disease, wa ter pollution, smell and environmental pollution, it was observed that the traditional latrine which is constructed by the participation of the communities has been welcomed and used by the community. In the baseline survey it was found out that inadequate sanitary conditions and poor hygiene practices played major roles in the increased burden of communicable disease within the village. Similarly, the baseline information stated that beneficiaries had problems with access to safe water and sanitation facilities. To this end, DCR Gambella set a strategy to solve the problems through community participation. DRC- Gambella inculcates the basic principles and approaches Sanitation) of into CLTS the (Community newly Lead Total PHAST designed Participatory hygiene and Sanitation Transformation) training. As both approaches opt for communities’ participations and empowerment and focus on igniting a change in sanitation and hygiene behaviour, a PHAST training manual that encompasses both PHAST methodology and catalysts for change in sanitation behaviour was prepared and distributed. After community based health promotions work, and community conversation establishments at each village, the accessibility to sanitation facilities and sanitation practices improved. 1446 households who completed hand washing points and traditional pit latrine (See the figure on the right side) were awarded NFI to recognize their efforts of behavioral changes.Hand washing after stool contact and safe disposal of stool have been priorities in hygiene and sanitation promotion interventions in Wanthowa Woreda. By understanding that for the quickest and widest adoption of good hygienic practices it is often more cost-effective to rely on social ambitions rather than health arguments to encourage change, DRC linked hygiene promotion works with social and cultural values, norms as well as NFI distributions, such that all hygiene promotions were linked with cultural problems of Nuer socie ty and social values. As a result good improvements in both hand 19 washing and safe stool disposal were registered. This can be confirmed by looking at the end line KAP survey results. 7. Waste and Waste Management The majority of disease measures are related to environmental conditions: appropriate shelter, clean water, good sanitation, and vector control, personal protection such as (insecticide-treated nets, personal hygiene and health promotion). Appropriate waste disposal mechanism is vital to avoid environmental pollution and breading place for vectors and pathogens. In this regards, the majority of the respondents (75%) indicated that they are now burning the household solid wastes on timely bases (Figure 24). The number of respondents who had been disposing solid wastes in open space and river significantly decreased after the interventions.Figure 24: waste disposal practice 20 The problems concerning waste were indicated in flies, bad smell, breeding place for mosquitoes. Majority of the respondents understood that appropriate solid waste disposal plays a vital role in minimizing the breading of vectors and other pathogens (Figure 25). Figure 25: Problems related to waste disposal The majority of respondents indicated that the practice used to dispose household waste is burning. Improvement in waste disposal and keep the villages clean is observed by DRC field staffs. Similarly the views of the majority of the respondents on the attributes of clean and health village is improved.It is noted that availability of safe water, cleanness of the village and availability of latrine considered by more than three fourth of the respondents as the attributes of clean and health village in the end-line survey. But those we stated the same were nearly 50% in the baseline survey. 21 Similarly, the benefits of keeping a village were mainly identified as decrease of diseases occurrence, improved beauty of village, minimized presence of mosquitoes and flies by more t han three fourth of the respondents in the end-line where as this nearly 53% in the baseline. From end-line survey, it can be inferred that majority of respondents indicated that important public health factors such as availability of safe water and atrines, absence of stagnant water and mosquitoes among the attributes of an healthy village. They also noted that this has great impact in reduction of infection disease prevalence. Hence, it can be concluded that the understanding of the majority of the respondents on disease transmission, transmission routes and its preventions tremendously improved after the interventions. 22 8 Conclusion Diarrhoea causes dehydration and kills approximately 2. 2 million people, mostly children, every year. Children are more likely than adults to die from diarrhea because they become dehydrated more quickly. In the past 10 years, diarrhea has killed more children than all of the people lost to armed conflict since World War II.Its occurrence is closel y related to the opportunities that poor people (especially poor mothers) have to improve domestic hygiene10. Diarrhoea does not only cause disease and early death in children, but also affects children’s nutritional status, stunting children’s physical and intellectual growth over time. Skin and eye infections are especially common in arid areas. Both diarrhoea and other infectious diseases have health as well as socio-economic consequences. Washing more often can greatly reduce their spread11 . Similarly, the training manual of Amhara region indicated that improved hygiene, particularly hand washing at critical times can reduce diarrhea by one third and reduce malnutrition12. Soiled hands are an important source of transmitting diarrhoeas.Recent research also suggests that hand washing is an important preventive measure in the incidence of acute respiratory infections, one of the top killer of children under five. 13 This KAP survey was conducted in order to compare its results with the results of the baseline survey, to identify whether the hygiene promotion activities conducted in the frame of the ECHO funded project had been effective. The baseline and end-line survey results revealed that positive results have been achieved in the overall hygiene situation. In the baseline survey the situation was poor i. e. lack of safe water, poor sanitation facilities, poor hygiene practice etc. At the end of the project, an improvement was noted in the overall hygiene and sanitation behaviour.Though improvements were noticed after the implementation of project, it should not be forgotten that it takes time to consolidate behaviour changes, so more follow up is necessary for further improvement. 10 11 12 (Curtis et al. , 2000). Brian Appleton and Christine van Wijk (IRC), 2003. Amhara Regional State Health Bureau, 2011; Isabel Carter, 2005 13 See for instance the study of Ryan et al. published in 2001 23 9 RECOMMENDATIONS Although the WASH project can be en seen as a success, the team noted some recommendations for future interventions. ? ? Construct 15 shell wells in Lolkuach village so that inhabitants meet SPHERE standards Assess whether it is possible to dig wells in the locations where people move to during the dry season ?Introduce rain water harvesting techniques, which are easy sources of potable water and would reduce the distance travelled to access water, thus improving the protection status of the women and girls that are responsible for this task. ? ? Follow up on well water quality in rehabilitated wells Although respondents recognized that animal feces can contaminate water, only 15% in the end-line noted that the proximity of a latrine to a water source can contaminate drinking water. This could be stressed and improved in future hygiene promotion activities. 24 10 References 1. Amhara Regional State Health Bureau (2011). Training Manual on Hygiene and Sanitation Promotion and Community Mobilization for Volunteer Com munity Health Promoters (VCHP)/ Draft for Review. 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