Water and Sanitation Household Survey at Project Level 2004 - Oromia Region

The questionnaire proposed here for household surveys on water supply, sanitation and hygiene at project level takes its starting point in this core set of water, sanitation and hygiene questions as reflected in the UNICEF/WHO Joint Monitoring Program (JMP)'s "Guide for Water Supply, Sanitation and Hygiene Related Survey Questions" and "Questions for Household Survey Module - Water Supply, Sanitation and Hand Washing", June 2004.

The JMP recommended questionnaire was adapted to obtain more detailed information on water, sanitation and hygiene in a geographically limited project area. In response to the specific requirements of the instruments, lessons learnt from more detailed and specific questionnaires have been taken into consideration, in particular those related to hygiene behaviour. Discussions with the World Bank both in Washington and in Addis Ababa, and the following documents, were the major sources of inspiration:
• The London School of Hygiene and Tropical Medicine's WASH survey method developed under the Water, Sanitation and Hygiene campaign of the Water Supply and Sanitation Collaborative Council (WSSCC), in particular Kristof Bostoen's water, sanitation and hygiene study in LAO PDR, funded by the World Bank.
• The Environmental Health Project's (USAID) report on Assessing Hygiene Improvement - Guidelines for Household and Community Levels.
• Boot, M.T. & Sandy Cairncross: Actions Speak - The study of hygiene behaviour in water and sanitation projects.

The questionnaire was tested by conducting qualitative interviews. In addition, a back-check questionnaire was developed for the quality control.

A set of picture cards were used to support the enumerators in understanding and asking questions on the different water supply and sanitation facilities. The show cards were based on those used in the World Health Surveys (WHO), supplemented by materials obtained from the Loughborough University Image Library and other sources. The quality of the illustrations can, to some extent, be improved in order to more clearly present the characteristics of a given technology and to take into consideration the variations in the design of the different technology types across countries and continents. Such improved illustrations are currently being procured by the WHO.

SUBJECTS INCLUDED IN THE QUESTIONNAIRE

1. Water supply

In accordance with the JMP questionnaire, reasonable access to water supply is assessed through questions on the following topics:
• main source of drinking water;
• main source and alternative source for other purposes;
• time to collect water;
• quantity of water used;
• individuals who collect water.
The term reasonable access has been adapted from the JMP in recognition of the need to further qualify access because access is a relative term that only exists as more or less/to a higher or lower degree, depending on the socioeconomic
and cultural context. The availability of an improved technology is not identical with accessibility, which depends on other factors such as the quality of the service, the location of the service, the reliability of the service etc. It has therefore been necessary to include generally acceptable standards or reasonable standards such as minimum quantity per person per day, minimum time spent on fetching water etc. Reasonable access measures the degree to which these standards are fulfilled and gives a more complete picture of access to water supply.
The main source type of drinking water provides an approximation for reasonable access understood as the availability of safe water of at least 20 litres per person per day from a source that can be reached within 15 minutes from the respondents' dwelling (approximately equivalent to one kilometre).
It is assumed by the JMP and others, for the purposes of making the surveys manageable, that certain types of technologies give an adequate supply of water, and these are accordingly defined as the improved water supply technologies.
Improved water sources are protected water sources, non-improved water sources are unprotected water sources. A protected water source is constructed in a manner that prevents water from being contaminated, particularly from surface
runoff (from rain, snow melt, or irrigation water). The following technologies are considered as improved:
• piped water into dwelling;
• piped water to yard/plot;
• public tap/standpipe;
• tubewell/borehole;
• protected dug well;
• protected spring;
• rainwater collection in closed containers.
Non-improved water supply facilities are:
• unprotected dug well;
• unprotected spring;
• rainwater collection in open containers;
• small-scale vendor;
• tanker-truck;
• surface water.
According to the JMP definitions, bottled water is considered non-improved because of concerns about the supplied quantity, not because of concerns about the quality. Here bottled water is treated differently. If the main source of drinking water is bottled water, the alternative source is used to define if the water source is improved. For instance in this report, if the alternative source is piped water into dwelling, the water supply is considered to be improved.
Water treatment is also included in the survey to discern whether households are treating the water before drinking.
As households frequently use alternative sources for other purposes than drinking, additional information is collected on the main and alternative water source used for bathing, washing, cleaning, etc. Questions on water transport time are included as an important determinant of access to water supply. Finally, a question on who fetches the water is included in order to obtain information about the burden from this work on women and children.
Compared to the JMP questionnaire, the proposed questionnaire has been supplemented with questions on the following topics to obtain a more complete picture:
• Handling of water during storage and for consumption: This is included as safe water from the source could be contaminated during storage and at the time of consumption if not handled properly;
• Seasonality is included because continuous access to improved water only applies if the household has access all year round.
• Reliability of water supply: Questions are included on the occurrence and duration of breakdowns. If the duration of breakdowns is excessive, i.e. more than one month in total during the last half year access is limited.
• Daily availability: Questions are included on the operation time of water supply facilities.
• Attitudes towards water services quality: This is to assess "reasonable access" in terms of the degree of the households' satisfaction with their water services such as water quality, distance, and stability of the services, etc.
• Expenditures on water, water treatment and water storage Experience gained from the trial of the WASH survey for water, sanitation and hygiene practices referred to in section 2.1 suggests that enumerators have difficulties in understanding and explaining the different water supply and sanitation technologies. Therefore visual aids (picture cards with drawings of the different technologies) are used for training purposes and to support the enumerators during field work. The visual aids are presented in Appendix 41 of the report.
Questions are combined with direct observations, as observations often achieve more accurate results, especially in the case of delicate issues such as cleanliness, hygiene, etc. "Water handling" is also assessed through observation, i.e. the condition and design of the storage container and water drawing devices.

2. Sanitation

In line with the JMP core questionnaire, "access to an adequate sanitation facility" is assessed through two questions:
• available sanitation technology;
• shared/non-shared facilities.
Knowing the type of sanitation facility used by a household provides information on the degree to which the facility meets basic sanitation requirements, i.e. if it hygienically separates human excreta from human contact. Meeting basic sanitation requirements is possible through the following facilities:
• flush to piped sewer system;
• flush to septic tank;
• flush/pour flush to pit;
• composting toilet;
• VIP/pit latrine with slab.
Facilities that do not meet basic sanitation requirements include:
• flush/pour flush to elsewhere;
• pit latrine without slab/open pit;
• bucket toilet;
• hanging toilet;
• open air/bush/field etc.
Whether a sanitation facility is shared with other households or is a public facility can impact its hygienic quality and in turn have an impact on its use. Shared facilities that are poorly maintained may be difficult for household members to use because of filth, odour and flies. Shared facilities - either private or publicare not considered adequate.
The JMP questions focus only on the type of available facilities. In the proposed questionnaire, additional indicators are included that measure the actual use of the facilities, cf. Appendix 1 of the report. Actual use is assessed by the presence of factors that are likely to encourage or discourage their use. The following are included:
• time to reach the facility;
• free access, signs of regular use;
• hygienic condition of facility.
If it takes a long time to reach the facility - if the facility is some distance away from the place of residence - this may discourage its use, e.g. by children or during the night. Whether a facility is actually used or not can be assessed by looking at certain conditions such as free passage (path is cleared, entrance not blocked, etc) and other signs of use. The hygienic condition of a facility is an indication of its use - unhygienic conditions are more likely to discourage its use. At the same time, the condition of the facility is an indication of hygiene practices.
Picture cards are used to assist the enumerators to identify/validate the type of sanitation available to a household. Also, questions are combined with observations.
The time it takes to reach the facility, the accessibility (indication of actual use) of the facility and its hygiene condition are assessed through observation.
The costs of building the sanitation facility and the costs of maintenance and repair are also assessed, because costs are important aspects.

3. Grey water discharge

Grey water consists of domestic wastewater exclusive of toilet waste. The rationale for including grey water is that from the point of view of "water hygiene" wastewater disposal is an integral part of the "water handling cycle" comprising drawing of water, storage, handling for consumption, reuse, and wastewater disposal.
Water used for cleaning clothes and nappies can be heavily contaminated with the same disease-causing organisms that hygiene and sanitation are intended to control. Stagnant water resulting from insufficiently drained grey water could also become breeding grounds for mosquitoes. Grey water therefore needs to be disposed of properly. The following observations are included to assess grey water disposal:
• mode of discharge of the household's wastewater;
• hygiene condition of the point of discharge.

4. Hygiene practices

Three questions are used to assess hygiene practices. They are concerned with:
• access to hand washing supplies;
• use of hand washing supplies at critical times;
• disposal of child faeces.
Hand washing is one of the most important preventive measures for reducing the prevalence of diarrhoeal disease. Whether a household has access to hand washing supplies such as soap can provide an indication of whether appropriate hand washing practices within the household are possible or likely. Along with appropriate hand washing supplies, hand washing at critical times is an important element of appropriate hand washing practices.
Knowing how children's faeces are disposed of is a critical aspect of hygiene improvement. Particular focus is placed on children's faeces because their faeces are more likely to be a source of contamination in the household environment than the faeces of other household members - and because in many societies they are considered harmless and therefore are not disposed of properly.
The JMP questions focus on the availability of soap alone, but in the proposed questionnaire soap alone is not considered a sufficient indication of appropriate hand washing practices, as soap may be used for other purposes. In many places/countries, no distinction is made between soap for hand washing and soap for other uses such as washing dishes, washing clothes, cleaning, etc.
It appears more useful to look at the entire "hand washing system". This is also supported by the WASH and EHP surveys, which find that the observed (concurrent) presence of items needed for hand washing, i.e. soap, water and basin, works best as an indicator for "good hygiene practice". For this reason, an observation is included of people's hand washing practices (they are asked to demonstrate how they usually wash their hands) to determine if the three prerequisites are present.
A fourth indicator of hand washing - the presence of a clean towel or cloth2 - is not used, as assessing cleanliness through the enumerators' judgement is very subjective while at the same time towels or cloths that are not clean constitute a health hazard.

5. Household characteristics

In addition to the core questions on water, sanitation, drainage and hygiene a number of standard questions on household characteristics are included to establish the households' socio-economic situation. Although this is not the main objective of the present study, this may allow for identification of the relationship between poverty/well-being levels and water, sanitation and hygiene conditions.