nfis kits post distribution monitoring. acf-paris too… · web view3.1.6 use of soap during hand...

ACF ZIMBABZWE WASH EMERGENCYCHIPINGE BASE UNICEF PROGRAM

Household NFI monitoring Report (PDM)May 2009

Picture 1Kits distribution in Chimanimani district

Picture 2Post distribution monitoring in Chipinge

district

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TABLE OF CONTENT

1 Objectives of the survey.................................................................................................22 Methodology........................................................................................................................2

2.1 Sampling......................................................................................................................22.2 Survey...........................................................................................................................3

3 Results and analysis.........................................................................................................43.1 Knowledge and practices towards Cholera.....................................................4

3.1.1 Knowledge on Cholera disease...................................................................43.1.2 Knowledge on Cholera transmission........................................................43.1.3 Knowledge on Cholera prevention............................................................53.1.4 Action taken in case of Cholera..................................................................63.1.5 Hand washing practices................................................................................63.1.6 Use of soap during hand washing..............................................................7

3.2 Post distribution monitoring.................................................................................84 Conclusion and recommendations..............................................................................9

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1 Objectives of the survey

In the scope of the program funded by UNICEF: Emergency response for the affected population by the cholera outbreak, in the Manicalands and Masvingo Provinces, Zimbabwe, PHHP sessions and kits distributions have been realized to 32 871 households in 203 villages.The objective of this survey is to monitor the use of the distributed items and the level of understanding of the session.Within a period of 1 week to three weeks after the distribution, a sample of HH is visited and interviewed on kits use and on knowledge and practices regarding Cholera.

2 MethodologyAs all HH and villages have been listed, it is easy to realise a random sample

from those lists.

2.1 SamplingThe statistical unit for these surveys is the household, assuming that water

and sanitation access as well as hygiene practices are homogenous inside a household.A household is a physical entity among which people are sharing income, houses and meals. To be simple we can consider that one household = one kitchen.

Considering the population (more than 32 000 households) scattered within a wide area, an exhaustive survey can not be realized. The sampling is done using cluster sampling method. 10% accuracy is admitted with 30 clusters.

The sample size is determined using the following formula:

N= t2 (p x q)d2

Were N is the sample size; t, the error risk parameter related to the confidence interverval (for ACF surveys, a confidence interval of 5%, which corresponds to t = 1.96, is assumed); p is the expected prevalence (for ACF surveys, a value of p = 0.5 is chosen, i.e. 50%); q = 1 – p, i.e. q = 0.5 for ACF surveys; d is the degree of accuracy admitted at 0.1 (10% accuracy) for this particular survey1.

N= 1.962 (0.5 x 0.5) = 960.12

The number of interviews to realize (96) is doubled in order to mitigate the cluster effect. To these 192 interviews, 15 are added to prevent incoherent answers making a total of 207 interviews to realize.

The clusters have to be equal in terms of size (207/30=6.9), meaning that 7 interviews are conducted per clusters. A total of 210 interviews will be realized in Chipinge district.1 Formula from ACF / Water, Sanitation and Hygiene for population at risk, Hermann, 2005

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Sampling is done as followed:

WARDVILLAGE

S HHNb

cluster Nb HHCHIP 3 22 3032 3 21

CHIP 16 15 3747 4 28CHIP 20 14 3244 3 21CHIP 21 25 2453 2 14CHIP 24 19 3234 3 21CHIP 25 21 3587 3 21CHIP 27 15 2500 2 14CHIP 28 14 3390 3 21CHIM 20 14 1864 2 14CHIM 8 11 1820 2 14CHIM 5 6 1385 1 7CHIM 3 7 1451 1 7CHIM 2 11 941 1 7

Total 32648 30 210Table 1: cluster distribution

The sampling step is 1088 (32648/30).

A cluster is considered as a village.The selection of the villages and of the HH is randomly done using a random number table. (Internet application generating random numbers cf http://stattrek.com/Tables/Random.aspx).

2.2 SurveyThe HH to interview and to visit are determined at the office. Once in the

village, the survey is explained to the village head that will assign someone to guide the surveyor during the survey. It is better if it is the VHW, so he/she is involved into the monitoring.

Knowledge and practices questionnaireThe visited HH will be questioned on the main messages related to the PHHP

session and their level of understanding of this session will be evaluated (knowledge part of the survey). See attached questionnaire (Appendix 1).

A guideline is attached to the questionnaire and is with the surveyor all the time to be used during the survey.

The objective of the questionnaire is to evaluate the level of understanding of the session done on Cholera prevention.

For each question, the answer can be correct, partially correct or incorrect, the level of understanding will be reported as:- Correct answer: GOOD- Partially correct answer: MEDIUM- Wrong answer: BAD

Kits monitoringThe presence and the use of the distributed kits will be assessed using the

monitoring form. The same HH reference is to be used for both forms.

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Part is based on observation, part on questions. Most of expected answer will be YES or NO. For the residual chlorine, the test will be done on the water used for drinking using a pool tester (see the interview form in appendix 1).

Data entry / analysisThe data are daily entered into an Excel database and analysed.

TrainingThe team followed half day training (theoretical and on the job training).

Methodology and questionnaires / forms have been tested on the field.

3 Results and analysisA total of 218 households have been interviewed among them 49 from

Chimanimani district and 169 from Chipinge district.

3.1 Knowledge and practices towards CholeraAmong the interviewed households, 72% directly attended the awareness session. The other interviewees had indirect transmission of knowledge form the household representative who attended the session or original knowledge on the topic from a different source.

3.1.1 Knowledge on Cholera disease The knowledge on the cholera disease is good for 81% of the interviewees.

More interviewees who attended directly the session gave the right answer (83%) compared to the ones who did not attended the session (75%). Nevertheless, the cholera appears as a well known disease.

Knowledge on Cholera disease according to attendance to the session

7% 2% 3%18%

15% 16%

75% 83% 81%

0%

20%

40%

60%

80%

100%

NO YES Grand Total

GOODMEDIUMBAD

Graph 1: Comparison of the knowledge on cholera according to the attendance of the session.

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3.1.2 Knowledge on Cholera transmission The knowledge on the ways of transmission of Cholera is also better for the

interviewees who directly attended the sessions (68% of them have a good knowledge) compared to the ones who did not attended the session (57% of them have a good knowledge).

Knowledge on Cholera Transmission

according to attendance to the session

12% 4% 6%

32%28% 29%

57%68% 65%

0%

20%

40%

60%

80%

100%

NO YES Grand Total

GOODMEDIUMBAD

Graph 2: Comparison of the knowledge on cholera transmission according to the attendance to the session.

In general, the transmission is well known for 65% of the interviewees only and 29% of interviewees gave partially correct answers. Generally the link with contaminated food and water and interpersonal transmission is clearly known, but the link with the faecal contamination is not obvious.

3.1.3 Knowledge on Cholera prevention There is a significant difference on the way of preventing from Cholera

between people who attended the session and the ones who did not. Indeed, only 50% of the non attending interviewees have a good knowledge on how to prevent Cholera compared to the 71% of the attending ones.

Knowledge on Cholera Prevention according to attendance to the session

8% 2% 4%

42%27% 31%

50%71% 65%

0%

20%

40%

60%

80%

100%

NO YES Grand Total

GOODMEDIUMBAD

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Graph 3: Comparison of the knowledge on cholera prevention according to the attendance to the session.

3.1.4 Action taken in case of Cholera

Action taken in case of Cholera according to the attendance to the session

7% 2% 3%17%

13% 14%

77% 85% 83%

0%

20%

40%

60%

80%

100%

NO YES Grand Total

GOODMEDIUMBAD

Graph 4: Comparison of the action taken in case of Cholera according to the attendance to the session.

The majority of interviewees are well aware of the necessity to rehydrate a suspected case, as well as referring him/her to the nearest health centre. The percentage of good answer is greater when the interviewees attended the hygiene session.

3.1.5 Hand washing practices Almost all the interviewees (98%) declared to wash hands after some critical

times such as before eating and after toilets whenever they attended the session or not.

Washing hands before cooking or after handling sick people were not given as an aswer for respectively 57% and 87% of the interviewees.

HAND WASHING PRACTICES

57%87%

98% 98%

43%13%

0%20%40%60%80%

100%

After toilet Before eating Before cooking After handlingsick people

YESNO

Graph 5: Time of hand washing practiced by interviewees7/12


There was no significant difference between answers given by attending interviewees and non attending ones except for the hand washing after handling sick people:

HAND WASHING PRACTICES

93%

85% 87%

7%

15% 13%

75%

80%

85%

90%

95%

100%

NO YES Grand Total

After handling sick people YESAfter handling sick people NO

Graph 6: Comparison of percentages of interviewees washing their hands after handling sick people according to the attendance to the session

3.1.6 Use of soap during hand washing

The use of soap (or ashes) is not systematic for 28% of the interviewees. This data were collected upon observation of the common way of hand washing demonstrated by the interviewees.

Use of soap when handwashing according to the attendance to the session

28%

68% 74% 72%

26%32%

0%

20%

40%

60%

80%

100%

NO YES Grand Total

YESNO

Graph 7: Comparison of the use of soap during hand washing according to the attendance to the session

In general, the knowledge on Cholera can be qualified as good for the majority of interviewees whether they have attended the sessions or not. There is nevertheless a positive impact from the session as knowledge of the attending interviewees is always better as the

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ones who did not attend the session; the differences between these two groups is from 8% (low significance) to 21% (high significance).

In a way, it is surprising to notice that the hygiene related knowledge on this disease is generally good and that the epidemic was so widely spread. This is suggesting that even though the knowledge is good, the practices may not be as good as claimed and that hygiene practices may not be the only responsible of the spread of this disease.

3.2 Post distribution monitoring

99% of the distributed main items (bucket with lid) were still in the household when the survey was conducted.

Use of the distributed bucket

25%

1%

34%

39%

Not use

Use fortransportonly

Use forstorageonly

Use forbothtransportandstorage

Graph 8: Percentage of use of the distributed bucket

25% of the buckets were not use, because they already have transport and storage facilities. This item is kept anyway by the households in case of future needs.

The above figures shows that needs are higher in terms of storage facilities that for the transport facilities as most of them already have transportation facilities. Indeed, very few households (1%) needed the bucket only for transport,

Generally the visited households were taking good care of the distributed items, and considering the short term after the items were distributed, those ones were in a good state. The distributed lids were used as 97% of the buckets used as storage facility were covered:

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Storage facility status

83%

14%2%

1%Storagecoveredand clean

Storagecoverednot clean

Storageclean notcovered

Storagenotcoveredand notclean

Graph 9: Percentage of storage facilities according to their status

The distributed soaps were present and used by 99% of the visited households. As the opposite, the use of the purifying tablets (Aquatabs) is not widely spread among the visited households:

Use of the disinfecting tablets (Aquatabs)

74%

21%5%

not used

good use

bad use

Graph 10: Percentage of use of the disinfecting tablets

The main reason claimed by the households for not using these tablets is because they are using safe source of water (according to them) such as borehole water. They intend to keep those tablets in case of a breakdown of the borehole. This is a very good preventive measure in one way, but the storage of these chemicals cannot be ensured at household level, increasing the risk of a bad use. It is also representing a risk in case it is handled by children. Some other given reason was mainly linked to the taste and smell of the water after using these Aquatabs.

The residual chlorine was measured for each household where Aquatabs was used and 65% of the results showed higher result than the recommendations given by MoH (0.5mg/L). It appears that the purifying tablets are way too strong for the volume of water to be disinfected. Although WHO is not pinpointing any particular danger to health with the obtained concentration, the smell and the taste of the water may turn people not using these tablets.

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4 Conclusion and recommendationsDespite a quite good general knowledge on Cholera, there is still one beneficiary out of

5 who does not how to properly prevent from Cholera, which may be sufficient to spread the disease.

Even is the accuracy (10%) does not allow to draw conclusion on some obtained results, the general trend shows that the sessions had a positive impact on beneficiaries’ knowledge regarding Cholera.

Such community sessions with a full coverage of the affected area are therefore recommended to keep the awareness effective among risky population. The message diffusion should be completed by a ongoing prevention trough key community actors such as the Village Health Workers and the teachers.

Even thought a quarter of the beneficiaries who received a kit did not really need it, this one is well used by the majority of the population.

The fact that the distributed transportation facilities were mainly used for storage, together with the fact that the distributed Aquatabs were generally not used (and representing a risk at household level) show that the distributed kits was not fully adapted to the needs of the beneficiaries.

The disinfection of the water at home should not been done using chemicals at household level, but using less strong product or done by well trained people upon needs in case of shortage of the usual safe water source.

Despite the fact that the kits were not adapted, the fact to distribute them dragged beneficiaries to attend to the sessions and allow ACF to cover 99% of the targeted population. Giving such incentives is a guaranty of touching the largest part of the population in addition to be an enabling factor for the population to safely keep water and adopt good hygiene habits.

ANNEXE 1 - POST DISTRIBUTION MONITORING FORM

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PHHP SESSIONS AND KITS POST DISTRIBUTION MONITORING

DISTRICT WARDVILLAGE SURVEYOR

HH ref Bucket in HH If not, where Use for

transport Use for storage Covered Clean Aquatabs used If not why Residual

chlorine Soap in HH Use of soap for Hand washing

Use of ashes for Hand washing

42 YES/NOSOLD / GIFT / EXCHANGE FOOD / EXCHANGE NFI /

STOLENYES/NO YES/NO YES/NO YES/NO GOOD / BAD/ NO BH water /

< 0.50.5-1

1> 1

YES/NO YES/NO YES/NO

HH ref What is cholera

Cholera transmission

HW After toilet

HW Before eating

HW Before cooking

HW After handling sick

people

COMMENTS:

In case of cholera actionCholera preventionSession attendance

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