Emergency WASH Assistance for Vulnerable IDPs in Suleymaniyah and Diyala, Iraq

January 2016

REPORT: ENDLINE ASSESSMENT FINDINGS

Executive Summary

Project title Emergency WASH Assistance for Vulnerable IDPs in Suleymaniyah and Diyala, Iraq

Project duration 8 months beginning 14 May 2015 and ending 13 January 2016

Assessed activity AMEU Endline Assessment Findings

Assessment date Mid-December 2015 to mid-January 2016

Main objective Assess the overall impact of infrastructure rehabilitation, hygiene awareness-raising sessions and kits distributions on IDP families living in informal, non-camp locations.

Specific Objectives:

1. Determine that collective shelter/informal settlement sites with WASH facilities meet minimum Sphere standards;

2. Assess whether emergency-affected population is provided with access to safe drinking water;

3. Determine knowledge retention of basic hygiene practices by targeted households following hygiene promotion activities;

4. Assess the quality, quantity, current use of and satisfaction levels on hygiene and baby kits distributed in target communities.

Locations Diyala governorate

Summary of main findings

Average family size is 6 members.

97 per cent had uninterrupted water availability during the day.

Two thirds of households are drinking from safe water sources.

More than three quarters treat their water before consumption; half of those who do not report that treatment is too expensive to afford.

All households have access to minimum 15 litres of water per day and 85 per cent possess two water containers per household.

56 per cent meet the SPHERE standard of having a water point less than 500 metres away from their dwelling.

ACTED WASH interventions led to a significant increase in perception of water quality (45 percentage points) by targeted communities.

99 per cent have access to a latrine facility, all located less than 50 metres from the dwelling in compliance with SPHERE standards.

Observed improvement in waste management practices as waste was visible in only one fifth of the sites compared to 90 per cent last year.

98 per cent are currently using their Hygiene Kit.

All households deemed their Hygiene Kit as very or partially useful, sufficient in quantity and of good or excellent quality.

The majority of households surveyed reported being able to implement safe hygiene practices (88 per cent).

Hygiene Promotion activities have had a positive overall impact on populations, although it is recommended to organize follow-up trainings on disease prevention and critical times for hand-washing to increase knowledge retention.

1. Introduction

ACTED has implemented a WASH project which aimed at providing 640 IDP households (3,840 individuals) residing in informal settlements with facilities meeting minimum WASH standards. The interventions included rehabilitation of sanitary infrastructures, connection of sites of intervention to existing water and wastewater networks through the repair and extension of piping, distribution of hygiene kits and baby kits and hygiene promotion activities to ensure that vulnerable IDPs are able to implement appropriate practices, reducing their risk of exposure to waterborne diseases in the long-term.

Overall objective: This assessment aims at determining the impact of infrastructure rehabilitation, hygiene awareness-raising sessions and kits distributions on IDP families living in informal, non-camp locations. Specific objectives:

1. Determine that collective shelter/informal settlement sites with WASH facilities meet minimum Sphere standards;

2. Assess whether emergency-affected population is provided with access to safe drinking water;

3. Determine knowledge retention of basic hygiene practices by targeted households following hygiene promotion activities;

4. Assess the quality, quantity, current use of and satisfaction levels on hygiene and baby kits distributed in target communities.

Indicators:

With these determined, ACTED Appraisal, Monitoring and Evaluation Unit (AMEU) will be able to evaluate the overall impact of the project after its liquidation through the following indicators:

# of emergency affected population provided with access to safe drinking water (3,850)

# emergency-affected population reached with improved sanitation (3,850)

per cent collective shelter/informal settlement sites with WASH facilities meeting minimum Sphere standards (100)

# of beneficiaries provided with hygiene and baby kits (3,850)

# of beneficiaries reached through hygiene promotion sessions (3,850).

2. Methodology

Baseline data was collected in February 2015 by the WASH teams, consisting of three engineers and two field staff. The objective of conducting a Baseline assessment was to identify the effectiveness and impact of hygiene promotion activities and distributions by comparing the initial results to the Endline data. Sample size chosen respected a 95 per cent confidence level and 5 per cent confidence interval, amounting to 299 households to be surveyed, although a slightly higher number was sampled (306 households).

Endline data for the targeted communities was collected by ACTED in three phases described below.

2.1. Hygiene Post-Distribution Monitoring After the completion of hygiene promotion activities in northern Diyala by ACTED WASH teams based out of Kalar with 1,164 households (5,748 individuals in total), ACTED AMEU conducted Post-Distribution Monitoring in the months of August and September 2015. Household participants were selected using random, on-site sampling with a 95/10 level of confidence/margin of error for a total of 94 household interviews, including 55 in Khanaqin and 39 in Kifri (see Table 1). The key messages delivered during the interventions were:

Hand-washing, personal hygiene and how to use cleaning materials;

Prevention of skin diseases through personal hygiene and careful sanitation;

Solid waste collection;

How to use chlorine tablets;

Cholera prevention (causes, symptoms, and treatment).

Table 1: Number of households interviewed during Hygiene Post-Distribution Monitoring

Governorate District Location # of households interviewed

Diyala Khanaqin Ali Sadun 14

Diyala Khanaqin Drawsha 19

Diyala Khanaqin Kani Masy 3

Diyala Khanaqin Mala Taib 2

Diyala Khanaqin Nuri Mekael 6

Diyala Khanaqin Qadr Beg 5

Diyala Khanaqin Shekh Mahdi 6

Diyala Kifri Ali Kalaf 29

Diyala Kifri Awaritaza 10

TOTAL 94

This assessment was the first part of a final evaluation for this project, which was completed by including further data collection following the construction and rehabilitation of WASH infrastructure and distributions of hygiene and baby kits in selected sites.

2.2. Hygiene Promotion post-Knowledge, Attitudes and Practices Survey (KAPS) Drawing on the pre-KAP study conducted in early 2015 as a baseline to gauge project impact for this assessment, ACTED AMEU conducted a post-Knowledge, Attitudes and Practices Survey (KAPS) using a 95/10 level of confidence/margin of error for a total of 96 household interviews, representing 587 individuals. Household participants have been identified using random, on-site sampling, weighted by location, amounting to 73 interviews in Khanaquin and 23 in Kifri as follows: Table 2: Number of households interviewed during Hygiene Promotion post-KAPS

Governorate District Name of site # of households interviewed

Diyala Khanaqin Ali beg 8

Diyala Khanaqin Ali sadun 9

Diyala Khanaqin Darawsha 11

Diyala Khanaqin Darwish 5

Diyala Khanaqin Homely 15

Diyala Khanaqin Kani massy 2

Diyala Khanaqin Mula taib 1

Diyala Khanaqin Nuri mekael 4

Diyala Khanaqin Qader big 4

Diyala Khanaqin Qaramin 11

Diyala Khanaqin Shek mahdi 3

Diyala Kifri Ali kalaf 17

Diyala Kifri Awaritaza 2

Diyala Kifri Shek Langar 4

TOTAL 96

2.3. Hygiene Kits and Baby Kits Post-Distribution Monitoring

In addition, ACTED AMEU conducted Post Distribution Monitoring following the distribution of

hygiene kits and baby kits to target communities using a 90/10 level of confidence/margin of error

for a total of 65 household interviews (Table 3).

Table 3: Number of households interviewed during Hygiene kits and baby kits PDM

Governorate District Name of site # of households interviewed

Diyala Khanaqin Ali sadun 8

Diyala Khanaqin Darawsha 8

Diyala Khanaqin Darwish 8

Diyala Khanaqin Homely 8

Diyala Khanaqin Karim Dawod 8

Diyala Khanaqin Qaramin 8

Diyala Khanaqin Shek mahdi 9

Diyala Kifri Shek Langar 8

TOTAL 65

In total, ACTED AMEU completed 255 household interviews, including

94 interviews for Hygiene Promotion Post Distribution Monitoring

65 interviews for Hygiene Kits and Baby Kits Post Distribution Monitoring

96 interviews for post-KAPS and WASH Standards requirements.

Completed surveys and interviews were uploaded via ODK to a password-protected server for

analysis by the AMEU Manager and Officers.

All survey tools can be located in the annexes shared along this final Evaluation report.

3. Background information

3.1 Family demographics

During the first Hygiene Post Distribution Monitoring conducted in August and September 2015, 94

per cent of households surveyed were male-headed, with the average age of the household head

42 years. ACTED AMEU always tries to ensure that survey participants also include female

representation – 16 per cent of all those surveyed were female, with the overall average age of

respondents 40 years. Family size on average was reported to be 5.9 people. A significant portion

of just over half (52 per cent) of all household members were children under 18. A large proportion

of families (22 per cent) contained pregnant women, and about 9 per cent overall contained people

with disabilities.

The beneficiaries for this project are all internally displaced households, primarily living in rural

areas (88 per cent), and all households surveyed were originally from within Diyala: about 60 per

cent from Khanaqin and the remainder from Khalis. Almost everyone surveyed had initially left their

area of origin (AoO) due to violent conflict, with an additional few who reported lack of livelihoods

or social tensions further causing their initial displacement (Fig. 1).

Figure 1: Reason for leaving Area of Origin (AoO)

One of the families living in the area were displaced as long ago as 2011, however the majority of families (90 per cent) have been living in the assessed areas since June 2014, which marked the greatest population influx (Fig. 2). Others arrived throughout last summer (9 per cent). A small proportion of families (12 per cent) had moved multiple times since initially leaving their area of origin, and those that had moved had done so on average 2.1 times.

97%

2% 1%

Violent conflict

Lack of jobs/income opportunities

Proglems within community withneighbours, authorities, etc

Figure 2: Date of arrival in shelter location from Area of Origin (AoO)

During the January post-KAPS, 91 per cent of households were male-headed with a head of households aged 48 in average. ACTED AMEU surveyed a fairly younger population with a respondent’s average age at 39 and ensured a gender-balanced representation among its interviewees, resulting in a sample divided between 41 per cent females and 59 per cent males. Family size amounted to 6 persons in average. Not many households reported to contain Persons with Disabilities. While a majority of households have to take care of minors as few families had infants and children under 4 and 17 per cent had children aged 5 to 17, a very small proportion of respondents reported to have elderly family members. Finally, during the second Post-Distribution Monitoring conducted in January 2016 with recipients of hygiene kits and baby kits, ACTED AMEU interviewed mostly men (93 per cent) aged 38 in average. Almost all households had been internally displaced inside Diyala governorates, in majority from Jalawla district, but two households originated from Baghdad and Kirkuk. Family size was reported to be in average 5.8 members; while more than one quarter reported to have baby girls under 2 in their household, this proportion increases to one third of respondents for boys the same age. Almost half of the households have girls aged 5 to 17, while almost two thirds of them have boys and male adolescents in the family. One out of ten households reported to have a Person with Disabilities (PwD) in their household as well. In summary, family sizes were in general fairly consistent across all locations, with an average of almost 6 family members. Respondents were on average 39 years old. Households are predominantly headed by men, 10 per cent of beneficiaries interviewed by ACTED AMEU were women in order to ensure a certain gender balance and perspectives in answers received. Figure 3: Family average demographics across communities by age and gender

0%

5%

10%

15%

20%

25%

30%20

11-0

6-01

2011

-08-

01

2011

-10-

01

2011

-12-

01

2012

-02-

01

2012

-04-

01

2012

-06-

01

2012

-08-

01

2012

-10-

01

2012

-12-

01

2013

-02-

01

2013

-04-

01

2013

-06-

01

2013

-08-

01

2013

-10-

01

2013

-12-

01

2014

-02-

01

2014

-04-

01

2014

-06-

01

2014

-08-

01

2014

-10-

01

2014

-12-

01

2015

-02-

01

2015

-04-

01

2015

-06-

01

2015

-08-

01

2015

-10-

01

0 0.2 0.4 0.6 0.8 1 1.2 1.4

Female

Male

Under 2 years old 3 - 17 years old 18 - 59 years old Over 60

3.2. Assistance received All households surveyed in September had received some form of humanitarian assistance since their arrival in their current location, primarily food assistance, NFIs, and shelter support (Fig. 3). However, this aid was rapidly decreasing at the time: only 4 per cent of respondents reported receiving food assistance in the previous 30 days. This was consistent with a decline in ACTED’s own food assistance in the second half of 2015 through the KR-I, which had been greatly reduced with rationed food either being distributed less frequently, or to a smaller, targeted population with targeting for food assistance being introduced by WFP in the country1. Figure 4: Type of assistance received before September 2015 by household

In addition, though only a quarter of households reported receiving water assistance, this may have been a translation error that did not specify WASH support, as data analysed below indicates that all families interviewed received hygiene promotion training from ACTED as well as hygiene items. It is possible that a common misunderstanding of this could be direct water trucking support or drinking water filtration systems. 3.3. Shelter and living conditions In September 2015, just under half of households interviewed were living within the host community, followed by those living in unfinished and abandoned buildings, showing a decline in the percentage of families being freely hosted from previous data collected in March 2015, when 75 per cent reported being hosted within the community2. However, ACTED AMEU continued collecting data on shelter and living conditions throughout the months of December 2015 and January 2016 to monitor the current situation as forced evictions and other tensions with host communities might put displaced populations at risk; most of the households reported to be hosted for free (almost three quarters of the populations), a figure similar to the one reported during the baseline; yet more than a quarter were paying rent to a landlord. None of them reported any issues such as threats of eviction or announcement of an unexpected rent increase for the coming months.

1 See report entitled: “Findings: July 2015 Post-Distribution Monitoring – WFP 10 CDX” released on 31 August 2015 2 See ACTED report “Pre Hygiene KAP (Knowledge, Attitude and Practices) survey: IDPs in Diyala and Wassit Governorates, Iraq” from 26 April 2015

98%

26%

2%

57%

99%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Food assistance Water assistance Fuel (gas, kerosene,etc)

Support for shelter NFIs (mattresses,plastic sheeting)

While more than half of the households live in a single room structure by the end of the project, another quarter is settled in an independent house or apartment. The other remaining quarter is divided between unfinished and collective shelters and other informal settlements. Only 1 per cent are staying in buildings or on land without permission from the landowner. All households have settled in their current shelter at various dates, however most of the IDPs arrived in June 2014 after the fall of Mosul to ISIS, corroborating information collected during the September PDM. They are all planning on staying in their current shelter over the remaining winter months, most certainly due to lack of alternative solutions. In terms of space arrangement, households live in an average of 1.5 rooms; almost one third of respondents do not have separated bathroom and kitchen. Among those who share their dwelling between multiple families, 80 per cent suffer from lack of privacy as they share all rooms and living spaces. In addition, 57 per cent of all households live in damaged shelters in need of minor or major rehabilitation. Among those, more than half have damaged or leaking roofs (54 per cent), damaged doors (23 per cent), broken windows (16 per cent) or damaged and cracked walls (4 per cent). Noticeably, many families are living in shelter suffering from multiple damages: almost one fifth have roof, door and windows damages and another fifth have both damaged door and roof (Fig. 5). Although the majority of households have an able-bodied household member or acquaintance who would be able to help with construction works (87 per cent), almost all households share that they would need technical support to make repairs to their home (98 per cent). Figure 5: Households shelter damages

Households were also asked on their general access to finances during the month of September; two thirds of respondents said someone in their family had worked in the last 30 days, and all of these said they were permanent positions. This seemed somewhat high as previous assessments conducted in the area showed that a low proportion of residents were employed at all3, and those that were employed were mainly in casual labour positions.

3 See most recent REACH MCNA reports from 2015

47%

18%

18.20%

5%

4%2% 2% 2% 1.80%

Damaged roof

Damaged rood, door and window

Damaged roof and doors

Damaged roof and walls

Damaged windows and roof

Damaged windows

Damaged windows and doors

Damaged doors

4. Findings on Result 1: Water supplies

The water supply needs of IDP girls, boys, men and women in the emergency and short-

term are met

AMEU objective:

Assess the ability of facilities to meet beneficiary drinking water needs

Relevant logframe indicator

# emergency-affected population provided with access to safe drinking water

ACTED AMEU has consistently monitored water sources of families across sites as WASH facilities rehabilitations were being completed. In September 2015, the most common sources of water were protected boreholes, though an alarmingly high number of families were relying on nearby rivers for drinking water, which does increase the health risks to the population, as river water is not deemed a particularly safe source of water. This had increased from 10 per cent of surveyed households in March 20154. As of January 2016, the proportion of households using protected boreholes or their own water network functioning over 2 hours per day stayed steady; however, the number drinking river water significantly decreased from 18 per cent to 6 per cent only (Fig. 6).

Figure 6: Water sources reported by families by project end

4 See ACTED report “Pre Hygiene KAP (Knowledge, Attitude and Practices) survey: IDPs in Diyala and Wassit Governorates, Iraq” from 26 April 2015

40.5% 11.5% 10.4% 9.4% 9.4%

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Protected borehole

Household water tap / network(over 2 hrs per day)2

Unsealed bottle

Water trucking

Unprotected spring

Sealed bottle

River

Public pipe

Unprotected borehole

While almost one tenth reported to rely on water trucking for water provision to their site by the end of the project, indicating an immediate need for further increased water infrastructure, especially in Ali Kalaf and Darwish sites, still a high proportion of populations relied on unsafe or unprotected water sources such as unsealed bottles (10 per cent), unprotected spring (9 per cent) and the river nearby (6 per cent). This result is worrying as more than one quarter of the interviewed populations is still drinking from potentially unsafe sources; moreover, amongst those, one quarter also reported that they did not treat their water before consumption. In terms of SPHERE standards, slightly over half of the targeted population had their nearest water point less than 500 metres away from their dwelling (56 per cent). Generally, Ali Sadun, Awaritaza, Mala Taib and Shek Mahdi have the highest number of households reporting a distance to water supply within Sphere standards. Kani Massy, Qaramin and Ali Kalaf are the most water insecure locations identified by ACTED AMEU. Further, almost all respondents had uninterrupted availability of water during the day (97 per cent) with exceptions in Ali Beg and Ali Kalaf sites. Generally, the latter shows distressing results in terms of water access as it falls out of SPHERE standards for water location and water availability and due to its high reliance on water trucking as a water source (29 per cent). ACTED AMEU does not test water quality as it is the responsibility of ACTED WASH teams, so the perception of good or poor quality is subjective to the opinions of respondents, rather than the laboratory testing. In order to determine water quality without conducting extensive water testing, ACTED AMEU asked households if they could describe the potable water they used on a daily basis. “Poor” water quality was further broken down into different characteristic such as taste, smell and observed presence of impurities, with only 11 per cent saying that their water tasted bad. This is a significant decrease in proportion compared to the month of September where 100 per cent of respondents reporting poor water quality describing it as having a “bad taste”. An additional 43 per cent of respondents also stated then that poor water quality was also defined by “bad smell” or “bad colour.” In January 2016, still one third of respondents deemed their water as unclean and potentially contaminated, however this 10 percentage point figure decrease is a positive sign of a continuous improvement of perceptions on water quality in the governorate of intervention. Overall, in February 2015, 87 per cent of households reported that the quality of the water they were drinking was “poor”. This had since decreased to 64 per cent in September 2015 and to 42 per cent in January 2016 along with ACTED continuous implementation of WASH rehabilitations throughout the area. The most widely spread reporting of poor water quality was then in Ali Sadun, Awaritaza, Drawsha, Kany Masy, and Shekh Mahdi villages. In January 2016, Ali Sadun, Darawsha and Shek Mahdi sites still considered that their water was not of good quality; however, half of the population in Awaritaza and Kany Masy now judge that their water quality is appropriate (Fig. 7). Figure 7: Perceived water quality by site by end of project

0.00%20.00%40.00%60.00%80.00%

100.00%

Good quality Poor quality (dirty, bad taste or bad smell)

While 91 per cent of households reported treating their water with chlorine tablets or through water filters in September, which was a huge increase from pre-KAP surveys conducted in March, when only 2 per cent of surveyed households reported treating their water, and was a significant achievement for ACTED WASH teams, only 77 per cent still treated their water by the end of the project (Fig. 8). This is a concerning result as the groundwater throughout northern Diyala is widely perceived by households to be salty or saline, and therefore generally requires high-quality water filtration systems. The 9 per cent of households who said they did not treat their water in September said it was because they then had no way of doing so. Although ACTED WASH teams have continued their intervention to improve water supply and quality throughout the area, this figure did not decrease but rather increased again significantly; half of those who do not treat the water they consume report that treatment is too expensive to afford, which shows an acute financial vulnerability of households that might not have the means to purchase new chlorine tablets once the initial stock received by ACTED is consumed. This indicates both an immediate and continuous need for distribution of water filtration systems and for strengthened hygiene promotion. Instead of chlorine tablets, main focus should be given to how to use filters that are a more sustainable solution for financially vulnerable households. Figure 8: Types of household water treatment

In terms of emergency Sphere standards, 100 per cent of households interviewed reported having access to at least 15 litres of water per day, including 64 per cent using 15 litres for drinking bathing, personal hygiene and cooking purposes and the remaining 36 per cent using 20 to 35 litres in average for the same purposes as well as clothes washing. This is a significant achievement as only three quarters of respondents of households reported sufficient access to water at the beginning of the project (78 per cent). An overwhelming majority of households interviewed reported having some means of storing water for personal use, a positive increase compared to last year where only 40 per cent of households possessed a water tank and 12 per cent did not have a household level water storage container, more than half of those drinking water from boreholes or the river. In total, 87.5 per cent of households have now access to a water tank and 92 per cent possess jerry cans (Fig. 9). Water tanks capacity usually amounts to one cubic metre of water stored as observed during field visits and confirmed by respondents. In addition, 85 per cent deem their available water storage as sufficient, meeting SPHERE requirement of two clean water collecting containers of 10–20 litres per household, one for storage and one for transportation. Of families that do have water storage, all reported covering their water storage for safe drawing and handling and 99 per cent did clean their container.

54%

67%

22%

24%

2%

23%

9%

98%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

End of project

Mid project

Beginning of project

Chlorine tablets Filters Other treatment (undetermined) None

Figure 9: Household water storage

5. Findings on Result 2: Sanitation

Emergency affected population access toilets and washing facilities that are culturally

appropriate, secure, sanitary, user-friendly and gender appropriate, including in learning

environments

AMEU Objective:

Installation or rehabilitation of washing facilities (showers, latrines), rehabilitation or

construction of drainage channels and provision of waste containers and plastic bags

Relevant logframe indicators

- # emergency-affected population reached with improved sanitation

- per cent collective shelter/informal settlement sites with WASH facilities meeting

minimum Sphere standards.

All households but one have access to a toilet facility, including 90 per cent improved latrines with cement slab, 5 per cent flush latrines and 4 per cent traditional open pit latrines. The remaining 1 per cent reports to be resorting to open defecation due to lack of alternatives. This is a substantial achievement for the WASH teams as one in ten households did not have access to a latrine last year and were practicing open defecation; others used traditional pit latrines without slab (82 per cent). Only one tenth had an improved latrine and no household had access to a flush latrine. This is particularly important as open defecation and poor latrine standards increase the likelihood of diarrhea; in February, two thirds of households resorting to Open Defecation practice reported to suffer from it.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Water tank, jerry can and plastic bottles

Water tank and jerry cans

Water tank only

Jerry can only

None

When asked about the total number of users per latrine, almost all households meet the SPHERE standard in early humanitarian emergency contexts of 1 latrine per 50 people (approx. 1 latrines for every 8 families); one tenth of respondents have 2 latrines per 8 households, 29 per cent report 1 latrine per 50 users, 60 per cent have 1 latrine per family. Amongst those, 93 per cent report that their available toilet is functional. Almost all households have the means and tools to maintain and clean their toilet facilities on a regular basis as reported by 97 per cent of respondents. The same proportion reported that the drainage system was operational. Toilets were all located less than 50 metres from the dwelling in compliance with SPHERE standards. According to SPHERE guidance note, family toilets are the preferred option whenever possible. However, when there is no previously existing toilet, 1 latrine per 50 people is the minimum starting requirement. Under this project, ACTED rehabilitated or constructed shared toilet facilities; as they are being used by several households, there are no separate toilets available for women as per 99 per cent of respondents. However, for future projects, it is important to bear in mind that toilets that are not arranged by household should be gender-segregated in order not to increase protection risks for women and girls. Besides, women might refuse to use a toilet facility that is also used by male non-family members as it was reported by female beneficiaries during a field visit in January. Toilets should also provide a minimum degree of intimacy. At the time of the field visit, all latrines could not be locked from the inside; however, this issue should be fixed by the supplier by the end of the project. In addition, latrines should always be provided with adequate lighting, which was observed not to be the case in some sites as the facilities were not connected to electricity; moreover, few sites encounter often power cuts. Thus head lamps, preferred over torches as they don’t require to be held by hand in the toilet, should be distributed to beneficiaries to enhance the safety of users at night, especially women and girls. Generally, households have access to sinks and/or taps in their house, especially in their toilet as 95 per cent of the targeted population reported to have an operational one. However, less than two thirds of respondents have a sink in their kitchen; amongst those, only 13 per cent said it was functioning. No communal laundry or bathing facility was available at any of the sites. Some of the showers installed by ACTED were being used as storage rooms by households when they already had existing basic washing facilities in their home, even though those were usually buckets only. In terms of solid waste management, the overwhelming majority of households had a garbage bin (93 per cent), which was the case for only 22 per cent last year, yet still 59 per cent burn refuse, over a third throw it in the open space and only 6 per cent stated that their municipality collects waste in their village. The latter fact explains these practices since people might throw waste in their garbage at first but have then no community waste collection system or disposal pit available. This was also confirmed during field visit where waste was visible at more than a fifth of the sites, which indicates a tremendous need for the organization of awareness-raising sessions on the importance of waste disposal with targeted communities and capacity-building trainings on waste management with local authorities. However, waste was visible at 90 per cent of the sites last February, thus it is important to acknowledge the radical decrease of this figure.

5. Findings on Result 3: Hygiene

Emergency-affected population has improved capacity to meet basic hygiene needs

AMEU Objective:

Ensure hygiene promotion messages are appropriately tailored to context and follow-up

to ensure knowledge intake and retention.

Relevant logframe indicators

- # beneficiaries provided with hygiene and baby kits - # beneficiaries reached through hygiene promotion sessions.

ACTED WASH teams distributed NFIs to households throughout northern Diyala, based on need and available items. Indeed, during pre-KAPS, it was found that although most households reported that they used soaps everyday (95 per cent) and that they could buy soap locally (96 per cent), two thirds of households did not have sufficient soap and hygiene items. One in four households reported that purchasing hygiene items was difficult to afford due to their generally high costs. All NFI kits distributed included a dust bin, a plastic bin, a plastic jerry can, soap, plastic jugs, garbage bags, disinfectant, and chlorine tablets, however due to the procurement process, there was a delay in some items, which explains why not all families had not yet received every single item in September 2015 and could not report on their use of the above-mentioned. By the end of the project, all households should have received all above mentioned items as well as hygiene kits, (1,544 households), simplified hygiene kits (1,850 households) and baby kits whose content is described below. Hence, ACTED AMEU decided to conduct an additional Post Distribution Monitoring following all NFI, Hygiene and Baby kits distributions.

Hygiene kits were composed of: Baby kits content is as follows:

While the Programme teams are responsible to report on Output indicators, AMEU still aimed at determining whether or not all households received complete kits as the content might vary due to logistical errors. While all households had received jerry cans, soap, garbage bags, disinfectant, sponge, floor gel, squeegee, washing powder and toilet paper, few households had not received some of the other items, with proportions varying between 1 to 9 percent depending on the item. This indicates that some items were missing from the Hygiene kits on arrival and calls for a strengthened communication with the donor once verification of the kits content by the Logistics Department in collaboration with Programme teams before the distributions start has been completed. Indeed, an uneven aid provision might create internal community tensions and a perception of discriminatory practices from ACTED side.

98 per cent are currently using their Hygiene Kit (Fig. 10); only one household reported to save the items for the future as they already owned some of them at home. Among the recipient households, almost all of them are using all the component items. A noticeable exception is toilet paper as no household reported to be currently using it. Indeed, targeted communities practice anal cleansing with water only. Although toilet paper is a standard item in the donor’s Hygiene kit for adults, it might be relevant to consider taking this item out of the kit in locations where it is not culturally adequate or rarely used. In addition, if of no use to the households, toilet paper might be thrown in the open, increasing pollution and waste management issues at the sites.

Dustbin

Plastic basin

Plastic jerry can

Plastic jugs

Garbage bags

Disinfectant

Sponge

Hand brush

Floor gel

Squeegee

Chlorine tablets

Bucket with cover and tap

Toothbrush

Toothpaste

Soap

Soap box

Shampoo

Plastic comb

Detergent

Towel

Safety pins

Washing line

Sanitary napkins

Toilet paper

Baby soap

Baby shampoo

Baby rash cream

Towel

Disposable diapers

Figure 10: Current use of Hygiene Kits

All households deemed their Hygiene Kit as very (three quarters of respondents) or partially useful to them, contributing to improve their capacity to meet their basic hygiene needs on a daily basis. Further, all of them declared that the kits were sufficient in quantity and either of good (80 per cent) or even excellent quality, showing high levels of satisfaction of the targeted populations. However, when asked if there were some items that would be required in greater quantity to cover their basic needs, a high proportion of households responded affirmatively; the most reported items were washing powder (89 per cent), soap (83 per cent), shampoo (65 per cent), disinfectant (54 per cent) and chlorine tablets (51 per cent). The variety of items included in the kit seems to have been suitable to the households’ needs as no additional item was mentioned when asked if anything else should be added to the kit. Amongst recipient households of Baby kits, all of them received a full kit with no missing item reported. An overwhelming majority of households (88 per cent) reported to be currently using the Baby kit; noticeably, one in ten households have donated it or are sharing it with another household that they saw as in greater need than their own (Fig. 11). This might be indicative of the need for a better targeting of beneficiaries, both through beneficiary selection by Programme teams and beneficiary verification by AMEU. Indeed, 12 per cent of households that received a Baby kit reported that they did not have a baby in their household; some community members also shared with AMEU that they had infants in their household, yet were not selected as beneficiaries for the distribution. Figure 11: Current use of the Baby Kits

98.50%

1.50%

Currently using it

Saved it for the future

88%

6.90%3.40% 1.70%

Currently using it

Shared it with another household

Gave it to another household

Not using it because already owneditems at home

Even though some of them were not using the items themselves, all households declared that the Baby kit was a very or partially useful kit to have. In addition, 97 per cent stated that the quality was good or excellent; 3 per cent saw it as average and stated that it could be improved. While only 1 per cent of beneficiary households reported that the quantity of items composing the Baby kit was not sufficient to meet basic hygiene needs while providing child care, a great majority of households still wished to receive more of almost all the items of the kit, especially a towel (85 per cent), diapers (three quarters of respondents), soap and shampoo (approx. two thirds of the households). All respondents stated they had received hygiene promotion training from ACTED WASH teams. To determine the impact of the information disseminated in these sessions, ACTED enumerators asked respondents if they could describe some of the material they remembered learning. The greatest response was regarding proper hand-washing practices and how to use chlorine tablets, followed by instruction on the importance of personal hygiene and the prevention of skin diseases. The least remembered sessions were towards solid waste collection (Fig. 12). Figure 12: Hygiene promotion awareness training reported by households

When asked about good hand-washing practices, almost all respondents knew to wash hands after using toilets, and before eating (Fig. 13). Very few knew to do so after handling baby diapers, which should be noted by WASH hygiene promotion teams. Though as the majority of respondents were male, they would be more unlikely to be handling babies’ diapers. During the pre-KAPS conducted in February, two thirds of households who had a child under two reported that they washed their hands after changing a baby’s diaper.

95%

70%

61%

74%

46%

93%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Handwashing Personal hygiene How to usecleaningmaterials

Prevention ofskin diseases

through personalhygiene and

careful sanitation

Solid wastecollection

How to usechlorine tablets

Figure 13: Reporting in good hand-washing practices

Though cholera outbreaks were on the rise across much of central Iraq and beginning to spread north5 in September, northern Diyala remained largely untouched. When asked which of a list of diseases family members had been affected by in the previous three months (Fig. 14), 74 per cent of respondents stated “none”. About a quarter of the population appears to have been affected by leishmaniasis in the last three months. All other diseases were surprisingly and safely reported in minimal numbers. 17 per cent of households reported at least one member of their family had lice in the last 30 days. The most common treatment for lice was reported to be shampoo and combs (81 per cent) followed by using some form of fuel such as kerosene. Figure 14: Diseases affecting family members in the 3 months preceding September

Another quarter of respondents reported children under 5 in their household had experienced repetitive cases of diarrhea in the last 30 days, and about 11 per cent of adults in households had experienced this as well. This was a significant decrease from pre-KAP data, which showed over three-quarters of households had children under 5 reporting cases of diarrhea. As respondents for this survey were primarily male, though, there is a chance that men are less likely to be aware of their younger children experiencing diarrhea, as childcare is primarily a women’s duty in the household.

5 OCHA is releasing regular cholera updates in 2015 through the WASH cluster

99%

81%

6%

0%

20%

40%

60%

80%

100%

After using toilets Before eating After changing babies' diapers

22%

1%

2%

3%

0%

74%

0% 20% 40% 60% 80% 100%

Leishmaniasis

Scabies

Hepatatis A

Respiratory infections

Tuberculosis

None

In order to gauge the overall impact of hygiene awareness activities and mitigate the risk of a cholera outbreak, respondents were asked to describe the causes of diarrhea they were aware of when presented with a list that included dirty water storage, poor hand-washing practices, drinking dirty water, and open defecation. Alarmingly, a third of respondents said none of the above, and a further 43 per cent said they did not know the cause of diarrhea. Less than a quarter said that drinking dirty water was the main cause of diarrhea (Fig 15). Figure 15: Reported causes of diarrhea according to respondents

This lack of awareness regarding the causes of diarrhea puts the population at high risk of water-borne diseases, and especially cholera. It is recommended that regular follow-up trainings on diarrhea and cholera prevention are provided to these communities. The endline data on diarrhea prevention does not differ much from the baseline conducted before hygiene promotion activities started and is indicative of a lack of knowledge retention on good hygiene practices. In addition to these concerns, 70 per cent of respondents said that in the case of diarrhoea, there was no treatment, while the remaining 30 per cent stated that they would go see a doctor (Fig. 16). ACTED AMEU purposely made the list of possible responses for this question quite broad, including general methods of rehydration to ensure the key message of hydration was understood by households. However, the fact that upon being presented with this list almost three quarters of respondents still said there was no treatment was alarming, and showed a lack of understanding on the importance of hydration as a key treatment to diarrhoea. ACTED WASH teams should emphasize the need for fluids replacement during diarrhea occurrence and provide targeted training on how to prepare home-made Oral Rehydration Solutions (ORS) with sugar, salt and water to prevent or treat dehydration, especially for small children.

22%

0% 0% 1% 0%

43%

33%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Drinking dirtywater

Not washinghands afterdefecating

Not washinghands before

preparing food

Dirty waterstorage

containers

Opendefecation

Do not know None of theabove

Figure 16: Reported diarrhea treatment by households

Overall, the majority of households surveyed reported being able to implement safe hygiene practices (88 per cent). For 12 per cent who found an assortment of different practices difficult to implement, the reason was always due to lack of access to water, especially clean water (Fig. 17). This was a noticeable improvement compared to results from the pre-KAPS as drinking clean water and daily bathing were considered as difficult for one third of the households due to lack of financial means, lack of access to safe drinking water and absence of hot water. The minimal 13 per cent of households that were not using the chlorine tablets in September 2015 reported they were not using them because they were considered “no longer useful to [their] household” and threw them away. This could be indicative of a misunderstanding of how to use the tablets, or what they were for. In January 2016, although one household reported not to have received chlorine tablets in its hygiene kit, all recipient households do use the chlorine tablets to treat their water. This might indicate a better understanding of the use of the tablets due to the Hygiene Promotion training provided by ACTED WASH teams, linked to a perception of increased need for water treatment since then. Figure 17: Most difficult hygiene practices for households

0%

0%

30%

0%

0%

0%

70%

0% 20% 40% 60% 80%

Give oral rehydration salts

Give more fluids

Refer to doctor/health clinic

Use medicinal herb such as stachys tea

Yogurt, and/or black tea with sugar

Water with lots of sugar and salt

Nothing

4% 3%2%

88%

1% 1%

Disposal of solid waste

Drinking clean water

Do not know

Nothing

Treating diarrhea

Washing every day

Conclusions

Overall, ACTED WASH intervention in Diyala governorate has had an overall positive impact on targeted populations. Access to safe drinking water In terms of SPHERE standards, all households have access to at least 15 litres a day with adequate and sufficient means of storage and almost all respondent households have now uninterrupted availability of water during the day (97 per cent); however, more than one quarter of the interviewed population is still drinking from potentially unsafe sources and water treatment before personal consumption is still not practiced by all households, main reason being lack of financial means to purchase new chlorine tablets. Hence, it is recommended that filters be distributed instead as they are a more sustainable solution for financially vulnerable households and that a short training be organized on how to use and maintain a water filter. Access to latrines Almost all households have access to a toilet facility, including 90 per cent improved latrines with cement slab. While this is a substantial achievement for the WASH teams as one in ten households did not have access to a latrine last year and were practicing open defecation, waste is still visible at some sites. Thus it is highly recommended to organize awareness-raising sessions with targeted communities on waste disposal and community disposal pits and further build capacity of local authorities and municipalities on solid waste management. All latrines are located less than 50 metres from the dwelling in compliance with SPHERE standards. In order to minimize protection risks and encourage all household members to use the latrines, it is recommended to build gender-segregated latrine facilities when shared by several households as women might not feel comfortable using toilets that are used by male non-family members. Besides, ACTED WASH teams could consider providing head lamps to beneficiary households, especially as power cuts are very frequent in sites of intervention. Disease occurrence, prevention and treatment Although diarrhea occurrence significantly decreased since last year, it should be carefully monitored as diarrhea instance increases with poor hygiene practices, overcrowding in shelter and lack of access to proper toilet and hand-washing facilities. When asked about the cause of diarrhea, 43 per cent could not answer. Alarmingly, over two thirds said that there was no treatment against diarrhea, which indicates a misunderstanding on diarrhea causes and lack of knowledge intake during hygiene promotion activities. The longer-term impact requires further support; hence, it is recommended that follow-up hygiene promotion sessions on the causes and treatment of diarrhea continue to be organized in order to mitigate the risk of water-borne diseases in coming months. ACTED WASH teams should emphasize the need for fluids replacement during diarrhea occurrence and provide targeted training on how to prepare home-made Oral Rehydration Solutions (ORS) to prevent or treat dehydration, especially for small children. Hygiene promotion An overwhelming majority of households surveyed reported being able to implement safe hygiene practices; all received Hygiene promotion training from ACTED. AMEU advises to organize follow up HP sessions as one out of three proposed critical times to wash hands were not known by respondents, especially after changing a baby’s diaper. Although men are less likely to be in charge of child care within the household, their participation to the hygiene promotion activities are key to a good overall understanding of good hygiene practices.

Quality and use of Hygiene kits In September, all families who received NFI kits have been using the items received and reported to be satisfied about their quality. By the end of the project, all households were satisfied about the quality of items received and 98 per cent were currently using Hygiene Kits. One component item, however, represented an exception as toilet paper was not being used by any household. Indeed, targeted communities practice anal cleansing with water only. Although toilet paper is a standard item in the donor’s Hygiene kit for adults, it might be relevant to consider taking this item out of the kit in locations where it is not culturally adequate or rarely used. In addition, beneficiary verification by AMEU should be made systematic after the selection by the Programme teams as baby kits were reported to have been distributed to households that did not contain small children or infant. Finally, items have been reported missing by a minority of respondents; thus it is recommended that the kits content are verified on an ad-hoc basis by Logistics and Programme teams to ensure a fair and non-discriminatory distribution of aid.

List of Annexes

Annex 1: AMEU Hygiene PDM

Annex 2: AMEU Hygiene kits and Baby kits Distributions PDM

Annex 3: AMEU Endline post-KAPS (Household Survey Questionnaire)