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Action Contre la Faim (ACF), Mongolia

Strengthening Local Capacities to Develop Access

to Water & Sanitation in the Ger Areas of Ulaanbaatar

Knowledge, Attitude & Practices (KAP) Survey on Water, Sanitation & Hygiene

Report from the Final KAP Survey

March 2009

Authors: Myagmarsuren Shagdarjav & Will Tillett

WASH Programme Ulaanbaatar Ger Areas, Mongolia

TABLE OF CONTENTS

TABLE OF CONTENTS...........................................................................................................2 LIST OF ACRONMYMS...........................................................................................................3 1 INTRODUCTION ..............................................................................................................1

1.1 The Purpose of this Document ..................................................................................1 1.2 The Ger Area Context ...............................................................................................1 1.3 ACF WASH Program April 2008-March 2009............................................................1 1.4 Objectives of the Survey............................................................................................2

2 METHODOLOGY .............................................................................................................3 3 LIMITATIONS ...................................................................................................................4 4 FINDINGS ........................................................................................................................4

4.1 Profile of interviewees ...............................................................................................4 4.2 Water Supply .............................................................................................................5

4.2.1 Water Sources & Consumption ..........................................................................5 4.2.2 Collection & Transport of Water .........................................................................6 4.2.3 Water Storage ....................................................................................................7 4.2.4 Water Treatment ................................................................................................9 4.2.5 Discussion ........................................................................................................10

4.3 Excreta Disposal......................................................................................................11 4.3.1 Latrine Usage ...................................................................................................11 4.3.2 Disposal of Children’s Faeces ..........................................................................12 4.3.3 Discussion ........................................................................................................13

4.4 Handwashing...........................................................................................................14 4.4.1 Discussion ........................................................................................................15

4.5 Domestic Hygiene ...................................................................................................15 4.5.1 Discussion ........................................................................................................16

4.6 Waterborne Diseases ..............................................................................................16 4.6.1 Discussion ........................................................................................................17

5 CONCLUSION................................................................................................................18 6 RECOMMENDATIONS ..................................................................................................19

6.1.1 Areas to Focus on In Future Hygiene Promotion in Ger Areas.........................19 6.1.2 Program Approach ...........................................................................................20 6.1.3 Schools & Kindergartens..................................................................................20 6.1.4 Sectoral Recommndations ...............................................................................20

7 REFERENCES ...............................................................................................................21 8 APPENDIX .....................................................................................................................22

8.1 APPENDIX 1: KAP Cluster Groups .........................................................................22 8.2 APPENDIX 2: The KAP Survey Questionnaire (English Version)............................23 8.3 APPENDIX 3: Satellite Map Showing Locations Springs, Schools & Kindergartens Included in the Project........................................................................................................28 8.4 APPENDIX 4: Profile of interviewees of Initial KAP Survey.....................................29

WASH Programme Ulaanbaatar Ger Areas, Mongolia

LIST OF ACRONMYMS

Acronym MeaningACF Action Contre la Faim

CNEA City Nature & Environment AgencyCPIA City Professional Inspection AgencyKAP Knowledge, Attitudes & PracticesMNT Mongolian TugrigMoH Ministry of HealthStdev Standard DeviationTTC ThermoTolerent Coliforms

USUG Ulaanbaatar water & sewerage service providers WASH Water, Sanitation & Hygiene

WASH Programme Ulaanbaatar Ger Areas, Mongolia 1

1 INTRODUCTION

1.1 The Purpose of this Document ACF undertook a one year Water, Sanitation & Hygiene (WASH) program between April 2008 and March 2009. This report summarises and discusses the result of two large Knowledge, Attitudes and Practices (KAP) surveys that investigated water, sanitation and hygiene issues in the Ger areas where the ACF program was implemented. ACF is now working on a new 3-year WASH program that started in March 2009, and the reader should remember this report relates only to the last ACF WASH program.

1.2 The Ger Area Context The city of Ulaanbaatar; Mongolia’s capital, has experienced a staggering rate of population growth in the past decade, rising from 100,000 in 1956, to over 1 million residents in 2007 (National Statistics Office, 2007). The urban expansion is due to the influx of rural migrants to the city looking for a new start, following successive droughts and harsh winters, as well as to gain closer access to education and medical services (UNDP 2004) The majority of settling immigrants locate themselves in the ever-expanding peri-urban informal areas, known as ‘Ger areas’, which extend outwards from the built-up centre (apartment areas). In 2007, the population of the ‘Ger areas’ accounted for around 60% of the total population of Ulaanbaatar city (ADB 2008). The Ger areas have inadequate basic infrastructure and services, such as water supply, sanitation, solid waste collection, drainage, central heating and roads. The urban environment suffers from surface and groundwater pollution due to inadequate sanitation, soil contamination from latrines and solid waste dumping, and air pollution due to thermal power plants and domestic stoves (World Bank, 2006). Water supply in the Ger areas is mainly provided by public kiosks, which may be a great distance from the user’s households, and often operate erratic opening times. The average consumption of water per person in the Ger areas is estimated at 4-8 litres per day, whilst ‘apartment’ residents may use over 280 litres per day (UNICEF, 2004). Water supply and sanitation have been found to be major priorities of Ger area residents (World Bank, 2006, JICA, 2006). The overcrowding in the Ger areas, coupled with poor hygiene habits of rural immigrants in the new urban context, and the poor sanitary conditions, pose risks for major environmental health problems in coming years. In 2007, 48% of all communicable disease cases in the country were reported in Ulaanbaatar, and the total (national) incidence was 22% over the previous 5 year average (MoH 2007). The incidence of Viral Hepatitis A; a disease spread by poor sanitation and hygiene, is seven times the international average in Ulaanbaatar (World Bank, 2006), and is on the increase (MoH 2007), in some districts at an alarming rate (see Appendix 4 for graphs). There are around 10,000 cases of diarrhoea every year in Mongolia, and 60% to 70% of these occur in Ulaanbaatar (World Bank 2006). The national incidence of dysentery is also on the increase, and 75% of all cases occurred in Ulaanbaatar in 2007 (MoH 2007). All of these diseases can be directly related to the poor sanitary conditions in the Ger areas, and the available health data indicates that the situation is deteriorating each year.

1.3 ACF WASH Program April 2008-March 2009 Action Contre la Faim (ACF) is a non-governmental, non-religious, non-profit making organization that was created in Paris in 1979. It currently has missions in over 40 countries worldwide, undertaking curative and preventative activities to address malnutrition in vulnerable populations. ACF’s main fields of work are nutrition, food security, and water, sanitation and hygiene (WASH).


ACF has been working in Mongolia since 2001; both in Ulaanbaatar, and Bayan Ulgi aimag undertaking multi-year food security and nutrition programmes. An assessment was done by ACF in 2006 on the water and sanitation situation in Ulaanbaatar Ger Areas, which highlighted issues in sanitation and hygiene in surveyed populations, and also identified spring water sources as significant potable water supplies for households. Indeed, the City Professional Inspection Agency (CPIA) has estimated that around 15% of Ger residents draw their water from springs across the city (ACF 2007). However, many of the springs are unprotected, and highly vulnerable to contamination. Based on recommendations of the assessment, ACF launched a one-year WASH programme in April 2008, titled ‘Strengthening Local Capacities to Develop Access to Water & Sanitation in the Ger Areas of Ulaanbaatar’. The project, which is officially partnered with USUG, the CNEA and the Municipality of Ulaanbaatar City, involves; protecting 15 springs, hygiene promotion, and capacity building local partners on water resource management. The programme has approximately 5,000 beneficiary households (approximately 25,000 people), and is being implemented across 5 districts of Ulaanbaatar City (Songino, Chingeltei, Khan-Uul, Nalaikh and Bayanzurkh). Fifteen springs were selected for spring protection, and the hygiene promotion activities primarily targeted the spring users (5,000+ households). The combination of improving the water quality of the spring sources, and improving domestic hygiene practices was intended to improve access to water supplies, and significantly reduce the incidence of waterborne disease in the beneficiary populations. The hygiene promotion activities for the program were undertaken between October 2008 and February 2009, and included:

• Targeted hygiene promotion sessions to 1205 vulnerable households, through community group sessions • Hygiene Promotion in local schools (5) and kindergartens (5) through the training of trainers and provision

of hygiene materials • The subsidised sale and/or distribution of 5,000 ‘improved’ domestic water containers to households,

schools and kidergartens in the selected spring areas. Based on the findings of the initial KAP survey, in addition to field observations and discussions with specialists in Mongolia, the following subjects were focussed on in the hygiene promotion sessions:

• Increasing the understanding of the routes of transmission of WASH-related diseases, particularly faecal-oral routes

• Handwashing with soap at key times (after contact with excreta and before cooking/eating/feeding children)

• The safe collection and storage of drinking water, and promoting basic water treatment • Raising awareness of the importance of safe excreta disposal (including children’s excreta) and methods

of low-cost improvements to domestic latrines • Safe food practices and diarrhoeal treatment

This program was completed at the end of March 2009, and now ACF is working on a new WASH program in other Ger areas of Ulaanbaatar.

1.4 Objectives of the Survey The Knowledge, Attitudes and Practices (KAP) Survey is a standard tool used in ACF WASH programmes to identify key issues and ‘risk practices’ in the target populations, along with providing baseline data upon which to monitor and evaluate programme impacts. At the beginning of the previous ACF WASH program an initial KAP Survey was done to identify key issues and risk practices of beneficiaries relating to WASH, and to inform the topics for the hygiene promotion sessions. The initial KAP survey is was used to provide baseline (pre-intervention) data which is then compared against results from a second (final), end of program KAP survey; to enable the comparison, monitoring and evaluation of the impacts of the program. The main objectives of this final KAP survey were to:

• Evaluate the impact of the Hygiene Promotion activities in the target area • Evaluate the project’s impact • Provide information for future hygiene promotion campaigns


2 METHODOLOGY

The final KAP survey was undertaken between the 19th February and 17th of March 2009 by ACF 6 field staff, and coordinated by the ACF hygiene supervisor. The areas selected for the KAP survey were the same locations of the areas selected for initial KAP survey, which was around the 15 springs that ACF protected, in order to target potential spring users. For each spring, the total number of households using the spring was estimated1, which subsequently informed the number of questionnaires to be undertaken for each spring area. The same cluster sample was used for the initial and final KAP survey. As the population to be surveyed was large and geographically scattered, a cluster sampling methodology was deemed to be most suitable. According to standard ACF sampling methodology2, where a representation with accuracy of 5% is desired, and when using 30 clusters, the total sample required, (including the doubling of samples to avoid the ‘cluster effect’) was calculated as 780 households. This was calculated using the following formulas:

t2 (p x q) 1.96*1.96(0.5*0.5) N = –––––––––– = --------------------------- = 384 D2 0,05*,005

The sample size N The error risk - t = 1.96 (5%) The expected prevalence - p = 0.5 (50%)

q = 1-p = 1-0.5 The degree of accuracy - d = 0.01-0.05

As the accuracy range is 5% d=0.05 To avoid the cluster effect, the sample size was doubled. N=384*2=780

Number of cluster is 30 Number of households in a cluster is 26 780/30= 26

The households were randomly selected for interviews by using the spinning bottle technique. A bottle was spun at the spring, which indicated the direction to go and choose the houses one after another. If the end of the street was reached before completing the sample, surveyors would go back to the spring and spin the bottle again. In total, using the random selection method around the springs, 780 households were interviewed, distributed over 18 khoroos of 5 districts (Songino, Chingeltei, Khan-Uul, Nalaikh and Bayanzurkh) across Ulaanbaatar city3. Regarding interviewee selection; where there was a choice of family members at a selected household, mothers would be selected preferentially, due to their key role in hygiene and sanitation within the family unit. The questionnaires were undertaken by 6 ACF field staff, accompanied by members of the Khoroo office, for health and safety reasons. The field staffs were monitored by the Hygiene Supervisor, and data from questionnaires was collected daily for inputting into a central database. The data entered was checked twice (to ensure data quality), before analysing using Microsoft Excel software. The questionnaire used was the same as that used in the initial KAP survey (to allow direct comparison of results). The questions (for the intial KAP survey) were developed with the kind assistance and input from experienced organisations in Mongolia, including UNICEF, WHO and the Ministry of Health. The questions covered a range of topics relating to domestic water, sanitation and hygiene practices, family health status and waterborne disease transmission. The initial KAP Survey questionnaire was revised and edited for the final KAP survey and was piloted for a half day. See Appendix 2 for a full list of questions asked.

1 The estimation was based on an initial field visit by ACF staff, and informed by local residents. The estimation was not based on household surveys, and was subsequently revised after the KAP following secondary ACF site visits. 2 From ACF E-Learning Self Training Module, KAP Survey (ACF 2006) 3 See APPENDIX 1 for comprehensive lists of Khoroos where interviewee households were located.


3 LIMITATIONS

Two limitations related to the quality of answers received are highlighted to the reader. These relate to:

• The quality of answers received and limitations of questionnaire & observational based research • The fact that the initial survey was undertaken in summer, and final survey was done in winter; with the

seasonal influence affecting both the demography of interviewees, and the hygiene practices of the respondents.

It was realised certain data collected may not accurately represent reality, either through (1) the ambiguity of the question asked, or (2) differences between answers that were given about practices (influenced by pride etc) and actual practices. An example of situation 1 is the question “does your water container have a lid?” The respondent may have a lid for it, but it may not actually be used. An example of situation 2 could be “how do you wash your hands”; where the respondent knows they should wash with soap, and answers that they do use soap (even if it is not true), so as not to seem like a ‘dirty person’. The latter example is an example of the ‘social desirability’ effect, which is difficult to avoid in KAP surveys for certain questions. Where data was to be collected through interviewer’s observations (such as whether a dishcloth is ‘sanitary’ or ‘unsanitary’), a process of subjective decision making took place. Although guidelines were used to make the decision as objective as possible, it is acknowledged that the different field staff members may have had different standards for the categorisation of their observations. The initial KAP was undertaken during the summer (average temperature around +17°C) and the final KAP survey was in February (average temperature -30°C). This may influence the answers by:

• The interviewee’s perception of reality, and thus the answers they give, was reflective of issues that occur in the summer months or winter, and issues experienced in the another season may not be ready in the mind of the interviewee.

• The domestic and personal hygiene practices may vary seasonally; therefore data collected is representative of one seasonal practice only. For example water consumption and personal washing frequency is higher in warmer months, and far lower in winter (when interviewees may only leave the house when strictly necessary, spring water sources are frozen etc).

The influence on results of the different seasons that the surveys were done should not be underestimated, and should be remembered by the reader throughout this report.

4 FINDINGS

4.1 Profile of interviewees The mothers of the households were interviewed preferentially over other members of the household when there was a choice, due to their importance and traditional responsibilities for WASH related issues in the household. The demographic distribution of interviewees was broadly similar in both surveys (see Appendix 4 for the profile of the initial survey interviewees). Out of the 780 persons interviewed in this final KAP survey, 52% were the wives of households and 28% were husbands. The average age of the participants was 44, and 47% of the participants were aged between 36-60 years old. For final survey the average household size was 4.35, and the maximum size was 13 . 37% of the interviewed households had children less than 5 years old, and 28% of included members above the age of 60. The average number of children under 16 in the households was 1.2 (Max 7, Stdev 1.2 ).


4.2 Water Supply

4.2.1 Water Sources & Consumption Most common sources of water collection for the interviewees were kiosks (truck or pipe fed), boreholes and springs. Other less common sources included wells, truck delivery and rivers. The usage of springs for water sources is reduced by over half in the winter, presumably as most of the sources are frozen solid.

Initial Survey Final Survey

In comparison to the initial KAP survey, the total number of spring users decreased for both summer and winter usage.

The reason that spring users gave for why they used the spring was mostly related to perceived health benefits of drinking spring water. The number of respondents who claimed the reason of collecting water was due to the difficulty of accessing alternative sources was high in first survey but in the second survey it was not so significant.


For the initial KAP survey, the average amount of money spent on water per household4 was 60 MNT (around $0.05) per day, although there was a large deviation between households (Max 300, Min 5, Stdev 41.5). The average daily water consumption per person also varied greatly, between 66l and 1.5l, with an average of 14.3l (Stdev 7.45). For the final KAP survey, the average amount of money spent on water per household per day was reduced to 40 MNT (with Max 300, min 0, Stdev 32.7). The average daily water consumption per person was dramatically reduced to 4.4l, (max 13 and Min 1, Stdev 1.9). The averge amount of money spend per HH per day Daily water consumption per person

4.2.2 Collection & Transport of Water In the final survey, in 45 % of households adult males were responsible for the collection of water for household use, in comparison to 39% in the initial survey. 15% of households claimed that the collection of water is the responsibility of the wife or daughter. In the final survey, ACF field staff observed that 69% of collection containers had narrow mouths and 70% had a lid. However for the initial survey found 77% of the containers have narrow mouths and 90% of the interviewees claimed the transport containers had lid. This difference is because the initial KAP methodology of assessing whether there was a lid was by question, and the second by actual observation. The final survey showed that the percentage of containers used for collection of water that were not manufactured to carry food or drinking water (such as petrochemical containers etc) was 44%. This shows a significant decrease in the use of petrochemical containers; as the initial survey showed that 83% of families were using containers not produced for water or food storage.



4 The average was only calculated for households claiming to pay for water, therefore not including spring users


4.2.3 Water Storage During the final survey, 72% of interviewees claimed to wash their storage containers at least once per week. This is in comparison to the initial survey where 90 % of households claimed to wash their containers at least once per week. The number of households who claimed to wash their container within in 3 days decreased from 60% (initial) to 25.3%.


For the initial survey, the most common method of washing the containers was by rinsing with water, and to a lesser extent, with soap. For the final survey, the number rinsing with water was decreased, but the incidence of effective washing (scrubbing) was increased. The proportion of interviewees washing with soap and water remained the same. For the final survey, 96.% of households emptied their water storage container once a week and 71.1 % of them emptied 2 and 3 days and 7% every day, but for the initial survey 99% of the respondents emptied their storage containers (used all its contents) at least once per week; with 28% everyday, 32% every 2 days, and 28% every 3 days. This reflects the higher water consumption (and thus faster turnover of the stored water) in the summer months.



As with the transport container, the data for the percentage of storage containers that had lids fell from 90% (initial KAP) to 66% (final KAP). This was again due to the change in technique from asking the respondents the question ‘does your container have a lid’, to the more accurate method of observation. The percentage of storage containers that had a wide mouth remained around the same (93% final, 93% initial). For the question about the way of taking water from the storage container; 96% of households collected the water by ‘scooping’ (dipping an implement into the water to take the water), and of this, 88% use a specific ladle used only for this purpose (and not used for cooking etc). 2% of them used taps on the containers. Picture 1: Industrial chemical containers on sale as water storage containers at a local market. 2: A l ady collecting water from the domestic storage container using a l adle. 3: The storage of a ladle on a food preparati on surface. 4: An ACF improved water container(75l, outlet tap, li d, hygiene sticker)

This is in comparison to the initial KAP survey, where 94% claimed to collect from storage by ‘scooping’, but with 78% using a specific purpose ladle. 0% interviewees claimed to take water using a tap in the initial KAP. This shows that whilst the incidence of ‘scooping’ has not decreased, more households are now using specific purpose ladles. 86% of households had different containers for the use of collecting and storing water. The number of households who has different container was increased by 5% in the final survey.


The percentage of households who use containers which are originally manufactured to hold food or drinking water was significantly increased from 13% (initial) to 58% final). This shows a significant reduction in the usage of petrochemical containers for drinking water storage.



4.2.4 Water Treatment When questioned how they know that water is unsafe to drink, 122 (out of 780) respondents answered that they didn’t know, and only 21 interviewees said if water is not boiled. For initial survey these results were 205 (don’t know) and 49 (if water not boiled). Many other responses were based on the physical characteristics of the water.

The percentage of respondents who claimed that they and their children drunk unboiled (raw) water decreased from 41% (initial survey) to 32% (final survey). Of those claiming to treat their water, boiling is by far the most common method in both surveys. Those who do not treat their water mention the reason is because they do not see it as necessary, rather than being prevented by shortfalls of knowledge or ability was decreased for the final survey.



The duration the respondents claimed to boil their water remained largely the same as in the initial KAP; 59% claimed they boiled and removed the water from the heat ‘as quickly as possible’ (the same as the initial KAP), 26% boiled for up to 5 minutes (23% in the initial KAP), and 18% more than 5 minutes (17% in initial KAP).

4.2.5 Discussion Many activities of the ACF WASH program were orientated around improving access, consumption and hygiene practices regarding the beneficiary’s drinking water practices. However due to the seasonal/climatic effect, the results of these activities are not so obvious in the collected data. The average consumption of water fell significantly between the initial and final KAP. This was expected, and is thought to be entirely related to climatic influences on consumption habits. It is suggested that it is related to;

• Reduced access to water (as the springs are frozen in the winter so spring users have to travel further to collect kiosk water)

• Collection of water in -30°C is an unpleasant task (cold, ice on roads etc). Therefore families reduce the use of water to a strict minimum to reduce the frequency of having to collect water

• The spring water is free to collect, but users have to pay per litre for kiosk water. This may reduce consumption

• Personal and domestic washing is far less frequent in the colder months. This can be caused by the unpleasentness of washing in cold temperatures, and the fact the household is trying to be sparing with their water in winter.

• Interviewees use spring water in large quantities in the summer months for domestic cleaning, causing large variations in consumption (which positively influenced the average figure for the initial KAP survey, and is reflected in the high standard deviation of the initial KAP survey water consumption figure). Such activities are not done during the winter months (reflected by a far lower standard deviation in average consumption in the final KAP).

• There may be additional influences such as seasonal variations on cooking practices and family income that have not been examined in this study

With reduced water consumption and ‘sparing’ habits with water; hygiene practices involving water (such as handwashing, dishwashing, container rinsing, personal washing etc) are reduced.


It may be that the use of domestic stored water is more ‘prioritised’ in winter months; with the primary use of water restricted for cooking and making tea, and the perceived ‘non essential’ uses (such as water for handwashing) are neglected. The average consumption figure of 4.4l/person/day is a serious cause for concern, as this is significantly below any national or international standard for the absolute minimum requirements for health. The total number of people claiming to use springs (both in summer and winter) fell between the initial and final KAP survey. The following possible explanations are suggested for this:

• A new kiosk was constructed and opened near to one or more of ACF’s protected springs between the times of the 2 surveys. This would mean less reliance and usage of the spring. This is the most likely solution, as the number of people mentioning ‘poor access to alternative sources’ as the reason for using springs also fell

• Another potential influence could have been people’s perceptions of the value/regularity of their spring use; as the spring had been frozen for months, and they forgot how much they use it in the summer.

There has been a significant reduction in the number of households using petrochemical containers for the transport and storage of domestic water. This is proposed to be related to both the activities of ACF distributing/selling improved containers in the areas around springs, but also through improved awareness raising of hazards of using such containers, communicated by ACF hygiene promotion activities. The number of households collecting water by ‘scooping’ has not reduced, but the practice of using a specific purpose ladle has increased considerably. This is thought to be as a result of training and awareness raising in the ACF hygiene promotion activities. The amount of users using the ‘tap discharge’ method which the ACF containers allowed were not significantly increased – basically people did not use the taps provided and continued to ‘scoop’ water. This could be due to the fact they did not have an ACF container, or that they did not use the tap. The latter is thought to be related to the fact that they have always used a ladle (difficult to change long-established habits), also they may not have truly perceived the benefit of using the tap in relation to the hassle of bending down to reach the tap and the relatively slow discharge of the tap relative to scooping water. It may have been related in some instances to the leaking of the tap and subsequent deliberate blockage. Unfortunately due to the change of technique for data collection, it was not possible to evaluate if people are now covering their water containers more. The total incidence of people claiming to treat (boil) their drinking water has increased. It is unclear however whether this is due to increased awareness due to ACF hygiene activities, or it may be influenced by the winter climate, when people prefer to drink hot water or tea.

4.3 Excreta Disposal

4.3.1 Latrine Usage For the final survey, 97.5% of respondents stated that for defecation they use a private latrine in their fence and 1.28% claimed they defecate in the open. This is in comparison to the initial KAP where only 86% of respondents had their own private latrine in their Khashaa, and 6% claimed to defecate in the open. The results show that the usage and private ownership of latrines has increased, and the incidence of open defecation has decreased.




When respondents who claimed to defecate in the open were questioned why they do not use latrines, the predominant answer was that they did not own one, or that they did not know why they did not use one. The 6% who responded to ‘other’ in the initial KAP survey related their reasons to the fact their pit was full.

4.3.2 Disposal of Children’s Faeces Of those with small children, 82% of respondents claimed to make their children defecate at home using a potty or with help and 11% of the children use pampers. 10% sent their children to the latrine, and 3% sent their children to defecate in the open. This is in comparison to the initial KAP were 15% were sent to defecate in the open, and only 10% were ‘helped’ at home. This indicates that parents are taking more care in the toilet training of their children, and shows the incidence of open defecation by children has decreased. Regarding the disposal of the children’s waste, the majority (87%) of respondents of the final survey claimed to throw it in the latrine, 11% dispose into their domestic garbage, and 2% throw it indiscriminately into the open. This is an improvement from the initial survey, where 9% claimed to throw it indiscriminately away, and 10% disposed of it in community garbage dumps.




4.3.3 Discussion The hygiene promotion sessions, and particularly the community sessions highlighted the risks of open defecation, faecal-oral disease transmission routes , and the importance of safe handling/disposal of children’s excreta. ACF used participatory approaches to make community realise their risky practices, and to mobilise the community against risky practices of sanitation. They also trained the community on improved designs for basic pit latrines. The observed reduction of open defecation and increased private ownership of latrines could be associated with increased awareness, community mobilisation to stop open defecation, or increased perceived benefits of sanitation. It could also be associated to the fact some interviewees in the first survey were recently arrived migrants that had not at the time built their latrine, but now had. It is suggested that is a result of both factors. The existence of a domestic latrine does not necessarily mean there is no open defecation. Children around 4-6 years old, and households who have a latrine with a full pit may still defecate in the open. Open defecation around latrines was observed in 3.5% of households which had latrine in their compound (final KAP). Given the density of population and the poor environmental sanitation conditions in the Ger areas (issues of solid waste and greywater disposal, vectors in summer etc), any open defecation can be seen as a serious risk to public health, and should be addressed. There seems to have been an improvement in the parental instruction on where they make their child defecate, and in the amount parents are ‘helping their child’, in addition to a general reduction in children open defecating. This could be due to the cold (children not defecating outside so much) and increased latrine ownership, but could also be related to increased awareness of the community to take responsibility of their children’s sanitary practices. It could also be through the awareness raising that children’s faeces is hazardous to health if not properly disposed of, just like adults faeces is. The practices of indiscriminate throwing or dumping of their children’s faeces have also seemed to reduce, with more respondents throwing it in the latrine or in the domestic garbage. This seems positive, but the results do not indicate whether the garbage bin is appropriately covered or not. There is belief that if a baby’s faeces are thrown to a dirty place the child will become sick. Therefore baby’s faeces are kept for a longer time in the home. This was dealt with in the ACF sessions by discussing the


hazardous nature of children’s excreta, and the need for safe disposal (if it must be kept in the house it should be in a sealed container away from food). Although it was not examined by the surveys, it was observed by the ACF field staff that many of the latrines in the Ger areas are poorly constructed, unhygienic and allow the proliferation and breeding of flies and other disease spreading vectors. The ACF community hygiene sessions included sensitisation of participants on low-cost improvements that could be achievable for their latrine. These were presented in the concept of the ‘sanitation ladder’, presenting possible low-cost improvements as steps that they could take, as and when they had resources available. These included:

• Applying a thin layer of ash onto pit contents in summer months to reduce odour and fly breeding • Closing the open spaces/holes between the pit and the outside (except for the squat hole of course) and

keeping the inside of the superstructure dark, to stop the entry and breeding of flies in the pit. • To add a basic ventilation pipe, and if possible to fit it with a fly-proof netting

In future surveys, ACF Mongolia will include an evaluation/observation of the respondent’s toilet features, to identify the issues and monitor improvements.

4.4 Handwashing Regarding the times that interviewees of the final KAP claimed to wash their hands, 54% said after defecation (increased from 35%), and 53% before cooking (increased from 26%). There was little variation in the results for handwashing after handling children’s excreta (8% initial, 6% final), and before eating (21% initial, 23% final). When questioned why they wash their hands, respondent’s answers predominantly related to maintaining hygiene and preventing diseases.



4.4.1 Discussion The hand washing sessions in the ACF program focused on handwashing with soap at key times including after defecation, after handling children’s excreta, before cooking and eating. During the sessions ‘Glo-germ’-hand washing training technology was used. This uses transparent gel that glows under Ultra Violet light. The gel is put on hands of trainees, and is used to show effective handwashing and hand to hand transmission of germs. It was found to be very effective, visual, and understandable method of promoting handwashing in school, kindergarten and community sessions. The results of final survey show that the respondent’s knowledge of the need for hand washing after defecation and before cooking has significantly increased. However it is not clear whether this new knowledge equals practice in reality. There was no significant change in the responses for handwashing after handling their child’s excreta, before eating or feeding children. The low incidence of hand washing after handling child’s faeces and before feeding children can put the children at risk to faecal-orally transmitted diseases such as Hepatitis A and diarrhoea. The children in the Ger areas are at high risk of waterborne diseases because of poor environmental sanitation conditions where they play outside (human and animal faeces, garbage etc). Children should learn handwashing from the earliest age, and the teaching should be seen as the responsibility of the parents, and of school and kindergarten staff. In areas where water access is difficult, and water is used sparingly, water is often not readily provided for handwashing. Promotion of handwashing should include advocacy to the school/kindergarten/household decision makers to always ensure water is provided for handwashing. The dominant way to dry hands after washing is with a cloth. If the cloth is dirty then it can instantly re-contaminate the clean hands. In the ACF hygiene promotion sessions we included addressing this issue, particularly looking at the improved storage (hanging) and frequent washing of the towels.

4.5 Domestic Hygiene When questioned how households dry their dishes for the initial survey 62% and final 67% answered they dry with dish cloths. For the initial survey 38% of house holds noted as unsanitary for final survey it was 25%.

In both surveys, the dominant practice of disposing of greywater was into domestic soak pits or into the latrine. The incidence of indiscriminate disposal of greywater inside or outside the compound increased from the initial to the final KAP survey. This is considered to be because in the winter the greywater would freeze in the pit latrine/soak pit and considerably reduce the effective volume of the pit. Therefore households dispose of it in the compound or on the street outside, causing considerable ice hazards. For the initial survey 58% and for final survey 70% of households keep domestic garbage in a container within the compound, whilst 12% deposit garbage indiscriminately inside or outside the domestic compound for the both the initial and final survey.



4.5.1 Discussion The indiscriminate tossing of greywater onto the ground inside or outside the khashaa (domestic compound) is a common issue across the Ger areas. In winter this causes serious ice hazards, and in the warmer months considerably degrades the environmental sanitation conditions and provides favourable conditions for vectors to breed. The ACF hygiene promotion sessions did not focus on solid waste or greywater disposal, as it was decided to focus on a small number of high risk practices (see section 1.2). This was due to the limited duration of the ACF WASH program. Longer term hygiene promotion programs could, and should address these issues. The issue of solid waste disposal can not be solved by hygiene promotion alone; an improved, affordable and regular service of garbage collection is needed, but also to be accompanied with awareness raising and mobilisation of the community about responsible solid waste management.

4.6 Waterborne Diseases Regarding the incidence of diarrhoeal disease, the number of respondents with children under 5 years old claiming their children had diarrhoea in the last 15 days fell from 8.5% (initial) to 7.1% (final KAP).



When questioned whether water can transmit disease, 26% (initial) and 22 % (final) mentioned they did not know, and 10% (initial)) and 8% (final) said that it does not. The number of respondents who said water can transmit diseases was increased by 6% in the final survey. Regarding the type of diseases that water can transmit, the knowledge that diarrhoea can be transmitted increased (323 mentioned in initial KAP, 385 in final KAP), and those mentioning Viral Hepatitis A increased from 69 (initial) to 164 (final).

4.6.1 Discussion

It appears that knowledge about waterborne diseases has increased, particularly in understanding that diarrhoea and dysentery can be spread via water. The knowledge that water can transmit disease increased slightly, but still a significant portion of the interviewees did not know this.

The slight drop in incidence of diarrhoea mentioned in the children of interviewees was insignificant to be able to derive any form of conclusion on the impact of the hygiene promotion on WASH disease incidence.

Indeed the fact that the beneficiaries of the program were so widely distributed (working with 15 small groups of beneficiaries at the sub-khoroo level) has made it very challenging to be able to validly monitor health center data and associate it with impacts from the program. In the future ACF intends to work in more geographically coherent target areas for this reason (along with logistical and organisational factors).


5 CONCLUSION

Whilst the data from the initial and final KAP surveys have their inherent limitations, and do not cover all issues, they give a useful insight into some of the key issues relating to WASH in the Ger areas, and particularly related to hygiene practices. The initial KAP survey was undertaken in July, and the second in February. Because of the strong seasonal effect on personal and domestic hygiene practices, and particularly on water consumption, not all results from the 2 surveys are directly comparable. This was unavoidable in this program however, given the timescales of the project. It is useful and interesting, however, to observe the seasonality of the hygiene issues and practices throughout the year, showing that there are different issues at different times of the year. The major issue identified in this final survey was the incredibly low average consumption of water in the winter, calculated at 4.4l per person per day. This is significantly below any national or international standards for the absolute minimum consumption recommended (WHO guideline is 20l/persn/day minimum). Whilst one of the ACF program objectives was to increase domestic water consumption, in reality hygiene promotion alone cannot increase water consumption. Major limiting factors of consumption are access to water (remembering that in winter springs freeze, and pushing a water trolley 500m across icy streets in -30°C is not easy). Other factors include affordability of water, and traditional practices of water ‘sparing’. Therefore it is proposed that to increase consumption, the issue of access should be addressed. This could be through domestic water connections (expensive in Ger areas), increasing the density and distribution of water kiosks, improving the service delivery capacity of the kiosks (opening hours, the tank and outflow capacity etc), and improving/protecting local water resources (such as springs). The dispersed nature of the ACF program beneficiaries (distributed in 15 areas around the selected springs) made the impacts of the program more difficult to accurately monitor. Also the targeted nature of the hygiene promotion sessions (to particular families, many of whom sent the grandparent to the sessions) and at some selected schools in the area, meant that the household and interviewee randomly selected for the KAP surveys were not necessarily beneficiaries of the program (attended a hygiene session or received and ACF container). Therefore the impacts may not have been seen as clearly as if ACF was undertaking the program in one coherent geographical area where all households in the area were program beneficiaries. Regarding the impacts, it is not always clear to know whether observed changes in knowledge and practices were related to the ACF program, or linked to other factors (climatic influences, media awareness raising by other organisations etc). However the key improvements, which could be attributed in some way to the ACF program include:

• A significant decrease in the use of petrochemical containers for water storage or transport (82% down to 42%)

• Increased number of households practicing ‘improved’ washing (scrubbing) of water containers • Increase in the number of households using only specific purpose ladles to draw water from storage • 10% increase in the domestic treatment (boiling) of water • Reduction of the incidence of open defecation by adults (6% down to 1%) and children (15% down to 3%) • Increase of private latrine ownership (88% up to 98%) • Improved practices of disposal of children’s excreta and ‘helping’ (potentially teaching) their child good

defecation practices • Significant increase in the knowledge of key times for handwashing, particularly for ‘after defecation’

(35% up to 54%) and’ before cooking’ (26% up to 53%) • Increased knowledge that key WASH diseases in the Ger areas (Hepatitis A and Diarrhoea) can be

transmitted by water Given that the hygiene promotion program was relatively short duration (4 sessions per community group plus activities over 2 semesters in schools and kindergartens), the impacts can be seen as having some considerable successes, particularly related to increased awareness of WASH disease causes, and handwashing at key times.


Knowledge, attitudes and practices take time to form, and time to change. A longer, more sustained hygiene promotion program that uses multiple medias to convey the messages (schools, kindergartens, community sessions in addition to television/radio) would be more successful at reaching all members of the beneficiary population, and holding a greater chance of success for behavioural change. Hygiene promotion alone cannot solve the issues of WASH in the Ger areas. Enabling factors need to be addressed, and appropriate technology options introduced and promoted, including demonstration models built in the community (such as improved latrine designs, effective greywater disposal units etc). The access to water should also be improved wherever possible. According to community comments, households have the desire to improve their environmental hygiene conditions, but financial barriers in addition to limitations of knowledge (and other infrastructural or public service limitations) are limiting barriers. Also there may be a lack of community initiative to improve their living environment. A part of an effective hygiene promotion campaign can be to mobilise the community to work together to improve their living conditions; for example by using the concept of ‘total sanitation”. Community hygiene promotion done by external organisations (such as NGOs) is often limited in its activities due to the finite presence in the community (depending on program budgets and timescales). Therefore it is important to develop the local capacity to undertake hygiene promotion, such as of local residents and organisations (community health volunteers, school/kindergarten workers etc). The involvement of local government, mobilising the community and training local trainers are all suggested as effective ways to bring about real, sustained improvements to the hygiene practices and environmental sanitation conditions in the Ger areas.

6 RECOMMENDATIONS

Based on the initial and final survey data, observations in the field and the experience of hygiene promotion activities in target area, the following recommendations are suggested:

6.1.1 Areas to Focus on In Future Hygiene Promotion in Ge r Areas X

• Further research is needed into appropriate models of domestic water storage, and modes to promote the use of the tap outlet. A ‘user preferences’ approach should be taken to ensure the ease of use of the container

• Further research could be useful to identify trends in water consumption through the year, and their impacts on personal, domestic and environmental hygiene practices. This could be correlated against disease incidence throughout the year, to see if there are key issues that should be targeted at key times through hygiene promotion/public awareness campaigns

• Mobilise the community against open defecation, indiscriminate disposal of excreta, solid waste and

greywater The community should put pressure on new arrivals to build latrines as a priority upon arrival.

• Address issues of poor domestic water storage, especially the practice of ‘scooping’, and the storage of the scooping ladle

• Future activites involving constructing and distributing/subsidised sale of water containers should build on

experiences learnt in this program. In the future it is recommended to develop a stronger partnership with a container manufacturer, to jointly produce, pilot, redesign appropriate and durable containers, that are constructed to the preferences of the users (identified in a household survey). One technical recommendation could be to produce containers on an elevated stand, so users do not have difficulties collecting water from the tap. Partnerships with the private sector and subsidising sales could be done effectively through a well-planned output-based subsidy.

• Promote appropriate, low-cost and basic technologies or improvement measures for improved latrines

and greywater disposal units. Present the options as a series of ‘steps’, using the concept of the sanitation ladder. Construct demonstration models in the community for them to observe and replicate


• Sensitise the community on the disease transmission routes of WASH diseases (particularly the faecal-oral routes)

• Promote handwashing at key times (before cooking/feeding children, after handling excreta or defecating)

• Advocate for the allocation of water in the household/institution for handwashing, even during times of

water ‘sparing’

• Messages should be prioritised, and communicated in a participatory way, maximising the use of visual aids and demonstrations to enable the audience to understand and relate what they are learning to their own life

6.1.2 Program Approach

• The hygiene promotion program should continue for long period as possible, and involve permenet local organisations

• Promote the training of trainers to undertake the hygiene promotion activities. Volunteerism could be

developed in hygiene promotion field

• Monitor program impacts periodically, and compare against results taken during the same season

• Consider implementing in one geographically coherent area to enable more accurate monitoring, and better targeting of beneficiaries

6.1.3 Schools & Kindergartens • Soap should be provided by schools on a permanent basis, and pressure should be put on decision

makers at the central government and at the school management level to allocate a specific budget for soap provision.

• Handwashing facilities should be provided and maintained in schools and kindergartens, and (for the case of sinks without piped connections) should be constantly refilled with water

• School and kindergarten staff should take an active role in promoting and monitoring basic hygiene

practices of the students; as the parents may not themselves practice or teach such practices (like handwashing) in the homes

• A school and kindergarten hygiene promotion manual should be developed appropriate to the children’s

particular age.

6.1.4 Sectoral Reccomendations

• A hygiene promotion manual and standard visual (IEC) materials should be produced, taking into account experience from a range of organisations, and shared with all organisations undertaking hygiene promotion. It could also be uploaded onto a website for free access.

• Survey data and survey reports should be sent to other projects and governmental and nongovernmental

organizations • All organisations working in the hygiene promotion sector should strive to further collaborate, share

information, and work together to improve the conditions of vulnerable populations in Mongolia.


7 REFERENCES

ACF (2007) ACF WASH Ulaanbaatar Project Proposal (November 2007)

ACF (2006) Water & Sanitation Assessment in Ulaanbaatar Ger Areas

ADB (2008) Energy Conservation and Emissions Reduction from Poor Households in UB

JICA (2007) Baseline Survey on Water Supply & Sanitation in the Ger Areas, Ulaanbaatar Ministry of Health (2008) National Health Indicators, 2007

National Statistics Office (2007) Mongolian Statistical Yearbook 2007

UNDP (2004) Poverty and migration in Ulaanbaatar

UNICEF (2004) Access to Water & Sanitation Services in Mongolia World Bank (2006) Hygiene & Sanitation Situation Report for Ger Areas, Mongolia


8 APPENDIX

8.1 APPENDIX 1: KAP Cluster Groups

Spring No.

District Khoroo Spring Name

Number of HHs Using

Spring*

Total number of HHs

Cumulative number of

HHs

Number of Clusters

Number of Interviews

2002009595707010010040407070

16 500Bayanzurkh 21 500

1501501501502722727070150150303090904040200200250250

4954 4954 4954 30 780

NOTES:

HHs means Households

Cluster Sampling Methodology

Spring number 2 & 10 were included in the KAP survey, as at the time they were initially included for spring protection. However these springs were later taken off the protection list, as spring 2 was to be protected by local government, and 10 for technical reasons

Totals

17 Khan-Uul 10 Morin 500 4954 3

400 Denjiin Myanga

Ekhiin bulag

Chingeltei end

2

400 2 52

12 190 590

1

Chi

ngel

tei

9

1 26

1 26

3 17 140 730

4 19 200 930Ar Sogootiin Ar Shuvuut 1 26

1010 1 26

6 15 140

5

Suh

kbaa

tar

15 804 modnii (Zuun modnii)

Shargamorit

Gunjiin

1150 1 26

5 1307 Dambadarjaaа 1000 2150

8 18 300 2450 2 52

2750 2 529

Bay

anzu

rkh

9 300Eej khairkan

Honhor's

Emegteichuudiin horih orchim

Uzuuriin

Baga amnii bulag

Gachuurt spa

10 11 544

11 11 140

3294 3 78

3434 1 26

5212 17 300

13 20

3734 2

2660 3794 1

14 20 180 3974 1 26

4054 1 2615

Son

gino

K

hairh

an 25 80Bayankhoshuu zuun salaa/

Hystain am

Baganaran16 4454 2 523 400

78

*Number of HHs using spring was based on an estimation by ACF field officers upon primary spring visits, and not based on HH surveys. This number has since been revised following sucessive spring visits. Each estimated number of spring users was doubled to be close to 5000 HHs, which is the ACF Hygiene Promotion target objective


8.2 APPENDIX 2: The Final KAP Survey Questionnaire (English Version)


8.3 APPENDIX 3: Satellite Map Showing Locations Springs, Schools & Kindergartens Included in the Project

-Spring to be protected

-School for Hygiene Promotion

-Kindergarten for Hygiene Promotion


8.4 APPENDIX 4: Profile of interviewees of Initial KAP Survey Out of the 780 interviewees, 52% were wives and 24% were husbands. Whilst priority for interviewing was given for mothers of the families (due to their importance in the families’ hygiene and sanitation), it was found to be impractical due to the large proportion of women in the workforce; and therefore unavailable at the time of interviewing. The average age of the participants was 42, and 49% were aged between 36-60 years old. The average household size was 4.45 persons, with a maximum of 15 and Standard deviation of 2.0. 40% of interviewed households had children less than 5 years, and 24% of households included member(s) above the age of 60. The average number of children under 16 in the households was 1.3 (Max 6, Stdev 1.2).

Age of Participants Involved in the Survey (Percentage)

120

16

26

23

12 210-1516-2526-3536-4546-6061-7576+

Household Demographics

0123456789

10111213141516

Nu

mb

er o

f P

eopl

e

Total number of inhabitants

Number of children

Interviewee Family Status (Percentage)

1278

24

24

52

WifeHusbandGrandmotherGrandfatherDaughter (above 15)Son (above 15)Daughter (below 15)Son (below 15)

knowledge, attitude & practices (kap) survey on water .... acf-paris toolbox/5.5 wash... ·...

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