Results from Baseline Household survey

1. Socio-demographic profile

The vulnerability status of the population at the V2R project areas was assessed during generic

assessment to identify the target audience. The project area targets the poor more vulnerable

population in terms of natural disaster and health risks. 500 sample households were assessed for the

baseline assessment from the targeted project areas on age and sex distribution, education and

employment level to understand their socio-demographic characteristics.

In the survey, 96% of the head of the household were male and only 4% of the head of the household

were female. Majority (44%) of the head of household were over 45 years of age. 28% of the

household were between 25-35 years of age, 27% of the household were between 35-45% of age and

only 1% of the household were under 25 years old in age.

98% of the sample household had been living in the area for over 5 years. Less than 1% of the

household have resided in the area for under 1 year period. Majority of the household (74%) have 2 to

5 family members. Less than 25% of the sample had 5-10 members in the family. 58% of the

household did not have any under 5 years old children. 39% of the sample had one child under 5 of

age and 2.8% of them had two children under 5 years of age in the household.

All sample households (100%) were found to be in a village area and majority (84.6%) of the

household had a clean environment. House and land ownership were taken into account for asset

assessment. 39% of the household were found to own a house as well as a land. About 25% of

household owned a house and had a land to farm on, and 21% of household had only a house as an

asset.

Majority (50.4%) of the head of the household had primary school level education. About 17% of

them had secondary school level education. Only 4% of them had higher education, compared to

27.4% who had no education at all.

Majority of the household (26%) were daily wage earner. About 24% of them were fisherman and

14% were farmers. 16% of them were self-employed. Only 6.8% of them were full time paid workers.

Rest were seasonal workers and contractual workers.

4. Hygiene status

Personal hygiene practices among the women respondents in the survey were found to be very poor.

Minority of respondents perceived most important hand washing practices as critical, as shown in

Graph A. Hand washing before eating (27.9%), after eating (22.5%) and after defecation or urination

(20.4%) was the most common perceived critical hand washing practices among the respondents. In

contrast, only 7.4% respondents perceived hand washing was to be critical before breast feeding or

feeding a child. Similarly hand washing was perceived to be critical before cooking or preparing a

food; and after cleaning a child bottom or handling faeces by 2.6% and 10.5% of the respondents

respectively.

Graph A

Before

Eating

Before

breastf

eeding o

r feed

ing a ch

ild

Before

cooking o

r prep

aring f

ood

After defe

cation/u

rinati

on

After cle

aning a

child

bottom/handlin

g fae

ces

After eati

ng

Before

praying

When m

y han

ds are

dirty

After cle

aning t

he toilet

or potty

Other (plea

se list

)

Does not k

now0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0% 27.9%

7.4%

2.6%

20.4%

10.5%

22.5%

3.8% 3.2%1.6%

0.0% 0.1%

% Household with Critical Handwashing Knowledge

Series1

Household will have good hand washing knowledge (score of 100%) if all critical hand washing times

is known by the respondents: Before eating, Before breastfeeding or feeding a child, Before cooking

or preparing a food, After defecation or urination, and After cleaning child’s bottom or handling of

faeces. Household will have fair hand washing knowledge for hygiene (score 60%-100%) if at least 3

out of 5 critical hand washing behaviour is known. Similarly household will have poor (scored <

60%) hand washing knowledge if less than 3 critical hand washing behaviour is known.

Survey showed that only 2% of the household have good hand washing knowledge (scored 100%),

36% of the household have fair hand washing knowledge (scored at least 60%) whereas majority of

the household had poor hand washing knowledge for hygiene at 62%, as shown in Graph B.

Graph B

% HH with good HW knowledge (score

100%)

%HH with fair HW knowledge (score at

least 60%)

%HH with poor HW knowledge (score

<60%)

0%5%

10%15%20%25%30%35%40%45%50%55%60%65%70%

2%

36%

62%

% Household by Level of Critical Handwashing Knowledge

Knowledge level of critical handwashing

It was found that only 11% of the sampled household washed hands near their latrine or kitchen: 4.4%

of household washed hand inside or within 10 paces of the toilet facility and 6.6% of the household

washed hands inside or within 10 paces of the kitchen and cooking place. 39.8% of household washed

hands elsewhere in house or yard. Most of the household (30%) had no specific hand washing site

while 17.8% of them had to go outside the yard to wash hands, as shown in Graph C.

Graph C.

Inside/w

ithin 10 pace

s of th

e toile

t facili

ty

Inside/w

ithin 10 pace

s of th

e kitc

hen/co

oking p

lace

No permiss

ion to se

e

No speci

fic plac

e

Outside y

ard

Elsew

here in

home or y

ard0.0%

10.0%

20.0%

30.0%

40.0%

4.4% 6.6%1.4%

30.0%

17.8%

39.8%

% Household Handwashing Sites

Series1

Majority of the household used water to wash hands (53%). Some household used Ash (9%), Mud or

sand (5%). Although 32% of the household stated that they used water with bar soap for hand

washing, only 27.8% of the household had water and soap available at the time of the survey, as

shown in Chart D.

Chart D

1%

32%

53%

9%5%

% of Household by Handwashing Agent UseI don’t wash my hands Water with Bar soap Water onlyAsh Mud/sand

27.8% had water and soap available

It was found that majority of the household did not have access to hand washing facility beside latrine

or near the house. 84% of the household did not have hand washing station inside the latrine or within

10 pace of the latrine. Only 16% of the household had hand washing station inside the latrine or

within 10 pace of the latrine and these household (16%) had water and soap were available at the hand

washing station at the time of survey.

16% of the household with hand washing station used bucket to wash hand, as shown in Chart E.

Rest of the household without hand washing station besides latrine or inside the house either washed

hand directly at the pond (29%) or tubewell (3%). 52% of the household had no arrangement to wash

their hands.

Chart E

16%

3%

52%

29%

% of Household with Handwashing Station beside the Latrine or inside the house

TapTippy TapBucketDirect Tubewell No Arrangement to wash handDirect Pond

Survey showed that majority of household suffered from fever of unknown causes (36.5%) in last 3

months. 16% of the household reported suffering from diarrhoeal illness in the last 3 months, as

shown in the Graph F.

Only 3% of the household last seeked treatment for illnesses from the private doctor, mobile clinic or

community health workers. 91.4% of the household seeked treatment directly at the pharmacy (non-

registered local doctor), whereas 5.4% of them did not seek any treatment at all.

Graph F

Diarrh

ea

Acute Resp

iratory

illness

/pneu

monia

Malaria

Fever

of Known Cau

se

No Illness

Other0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%

16.0%

6.4%1.6%

36.5% 37.9%

1.6%

% Household Disease Prevalence in last 3 months

Series1

Thirst and sunken eye were the most common danger signs of dehydration known by the household.

Household will have good knowledge of danger signs of severe dehydration from diarrheal illness

(score of 100%) if all 4 important danger signs are known by the respondents: Sunken eye, lethargy,

unconsciousness, and loss of skin elasticity. Household will have moderate knowledge of danger signs

(score 50%-100%) if at least 2 out of 4 signs are known. Similarly household will have poor

knowledge on danger signs (scored < 50%) if less than 2 danger signs are known by the respondent.

Survey showed that none of the household (0%) has good knowledge of danger signs; only 7% of the

household have moderate knowledge of danger signs whereas majority of the household at 93% have

poor knowledge of danger signs of severe diarrheal dehydration as shown in Graph G.

Majority of the household (40.4%) practiced using ORS (Oral Rehydration Solution) packet during

episodes of childhood diarrhoea. Only 19.2% of the household used homemade sugar, water and salt

or ORS solution, 20.8% of the household practiced continued exclusive breastfeeding. Similarly,

about 7.5% of the household increased homemade fluid intake while few household (1.5%) used zinc

as treatment, as shown in Graph H. It was found that 90.4% of the household knew the method to

prepare ORS at home or to prepare ORS from pocket as per the packet instruction.

Graph G

% of HH1 with high knowledge (score 100%)

%HH1 with moderate knowledge (score 50%-

100%)

%HH1 with low knowledge (score <50%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

7%

93%

% Household by Level of Knowledge on Danger Signs of Severe Diarrhoeal Dehydration

Series1

Graph H

0%

10%

20%

30%

40%40.4%

19.2%

7.5%

20.8%

1.5% 3.6% 0.5% 3.1% 3.5%

% Household practices against childhood diarrhoeal illness

Series1

Household will have good knowledge of measures against diarrhoeal illness (score of 100%) if all 5

measures are known by the respondents: ORS, increased home-made fluid, continued breast feeding

and zinc treatment. Household will have moderate knowledge of measures against diarrhoeal illness

(score 60%-100%) if at least 3 measures are known. Similarly household will have poor knowledge of

measures against diarrhoeal illness (scored < 60%) if less than 3 measures are known by the

respondent.

Survey showed that none of the household (0%) has good knowledge of measures against diarrhoeal

illness; only 22% of the household have moderate knowledge of measures against diarrhoeal illness

whereas majority of the household at 78% have poor knowledge of measures against diarrhoeal illness

as shown in Graph I.

Graph I

% of HH with high knowledge (score 100%)

%HH with moderate knowledge (score 50%-

100%)

%HH with low knowledge (score <50%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0%

22%

78%

% Household by Level of Knowledge on Measures against Diarrhoeal illnesses

Series1

The main source of information on diarrheal diseases and hygiene came from community health

workers (38.4%), friend and neighbours (11%), family members (9%) and mass media such as TV

and radio (9%). 13.2% of the household had no source of information. None of the household had

received information on diarrheal diseases and hygiene from Water and sanitation committee in the

community as shown in Graph J.

Graph J

Friends and NeighborsCommunity Health Worker/ outreach workers

Community health volunteersFamily member/ mother in law

Clinics, Hospitals and PHUsSchool teacher or children

Community DramaReligious leaders

Mass media (TV/radio)Newspaper

Books/posters/brochuresWater and sanitation committee

Red crescent volunteerWord of mouth

No bodyOthers

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%11.4%

38.4%5.4%

9.0%3.8%

0.0%0.2%0.0%

9.0%0.0%0.0%0.0%0.0%

9.6%13.2%

0.0%

% Main source of Information on Diarrhoeal diseases and Hygiene

Survey showed that majority of the household (63%) perceive hand washing at key times as the most

difficult hygiene behaviour to change, as shown in the Chart K. Use of latrine and use of clean

drinking water was perceived as the hardest hygiene behaviour to change by 17% and 13% of the

household respectively. And only 7% of the household perceived disposal of children’s stool as the

hardest hygiene behaviour to change.

Chart K

13%

17%

63%

7%

% Household by Hardest Hygiene Behavior to Change

Use of clean drinking waterUse of latrinesHand washing at key timesDisposal of children’s stools

Summary of Results for Hygiene and Diarrhoeal disease status

A. Hand Washing and Hygiene Behaviour Status

a) Baseline household survey:

Personal hygiene practices among the respondents in the survey were found to be very poor.

Although hand washing before and after eating, and after defecation or urination was the most

common perceived critical hand washing practices among the respondents, only a minority of the

respondents felt that hand washing was critical before cooking or preparing a food; after cleaning

a child bottom or handling faeces and before breast feeding or feeding a child. Only 2% of the

household have good perception of all critical hand washing practices (scored 100%), 36% of the

household have fair perception of hand washing practices (scored at least 60%) while majority of

the household have poor perception of hand washing practices for hygiene at 62%. This indicates

a need to change perception of hand washing for hygiene and promote critical hand washing

behaviour.

Majority of the household did not have access to hand washing facility beside latrine or near the

house. Only 16% of the household washed hands using a bucket inside/within 10 paces of the

toilet facility. Rest of the household without hand washing station besides latrine or inside the

house either washed hand directly at the pond (29%) or tube well (3%). 52% of the household had

no arrangement to wash their hands. These indicate a need for hand washing facility to enable

household to wash hands at critical times.

Household were practicing hand washing with mainly water (53%). Some household used Ash

(9%), Mud or sand (5%). Although 32% of the household stated that they used water with bar

soap for hand washing, only 27.8% of the household had water and soap available at the time of

the survey.

It was found that majority of the household (63%) perceived hand washing at key times as the

most difficult hygiene behaviour to change. This may be linked with the lack of adequate hand

washing facilities inside or near latrine or house and that soap was not always available for hand

washing.

b) Focus Group Discussion:

Discussion from the both communities Halwa and Dema highlighted that no one practiced hand

washing and that hygiene practices were not followed by people. Communities believed that good

hygiene was important to prevent illness and to feel clean. Some also felt that it is important to

have a good hygiene to reduce diseases, and reduce extra expenditure; moreover it means relief

from the sickness, which will enable them to produce more work. People in communities did not

receive any hygiene and sanitation education. These findings validated the baseline survey

findings that there is poor hygiene practices due to lack of adequate information on health and

hygiene among people in the community. Although people in the community showed good

perception of diarrheal risk due poor hygiene practices, the level of awareness on hand washing is

low resulting into poor hygiene practices.

c) WASH Community Engagement Assessment:

WASH community assessment exercises showed that majority of the people in the community did

not wash hands or practiced covering their food. Although community identified hand washing

and covering food as effective barriers to disease transmission route, community also stated that

hand wash behaviour was not very easy to practice mainly due to lack of money to purchase soap

for washing hand.

Other barrier for changing poor hygiene behaviour was to develop a habit which takes time.

However if both male and female motivates each other to use soap then the community agreed

that it is possible to reduce diarrhoea.

Other poor hygiene practices identified by the community participants were open field defecation,

eating dirty food. Awareness on hand washing and clean latrine were identified as important

hygiene practices that should be promoted in the communities.

It was found that men could contribute more in maintaining hygiene by washing hand after

returning from the field and also support by providing women with regular supply of soap.

B. Diarrhoeal Disease Knowledge, Perception and Practices

a) Baseline household survey:

Survey showed that 16% of the household reported suffering from diarrhoeal illness in the last 3

months but only 3% of the household last seeked treatment for illnesses from the private doctor,

mobile clinic or community health workers. 91.4% of the household seeked treatment directly at

the pharmacy (non-registered local doctor), whereas 5.4% of them did not seek any treatment at

all. This shows that there is a high diarrheal prevalence in the community though people did not

seek appropriate treatment.

It was found that none of the household (0%) had good knowledge of danger signs of severe

dehydration resulting from diarrhoea. Only 7% of the household had moderate knowledge of

danger signs whereas majority of the household at 93% had poor knowledge of danger signs of

severe diarrheal dehydration. This indicates the need of knowledge in the community on danger

signs of severe diarrheal dehydration to detect the signs immediately and seek treatment as early

as possible.

Although most of the household practiced using ORS (Oral Rehydration Solution) packet during

episodes of childhood diarrhoea, only 19.2% of the household used homemade sugar, water and

salt or ORS solution, 20.8% of the household practiced continued exclusive breastfeeding.

Similarly, about 7.5% of the household increased homemade fluid intake while few household

(1.5%) used zinc as treatment. This indicates the need of knowledge in the community on

appropriate home based measures against diarrheal illnesses.

The main source of information on diarrheal diseases and hygiene came from community health

workers, friend, neighbours and family members. None of the household had received

information on diarrheal diseases and hygiene from Water and sanitation committee in the

community. This indicates that local level community awareness event; peer and family

education approach etc be appropriate methods to promote hygiene and health in the community.

b) Focus Group Discussion:

Discussion from the both communities Halwa and Dema highlighted similar issue with access to

treatment. There were no registered doctors or health practitioners in village hence people seeked

treatment from local healers or nonregistered doctor at the pharmacy. Outreach worker from the

Government Family Planning Programme visited the community once a month to promote family

planning but sometimes provided with free ORS. Community also received services from the

Government Immunisation Programme. In case of severe illness, people travelled to District

Hospital by boat which was very costly.

Most vulnerable groups are pregnant women and elderly who need treatment. The community

depended on guardian or took loan in case of illnesses, as there are a few coping mechanisms

during such health crisis. It was stated that there is no known active case reporting to the Health

Unit in case of diarrheal illness in the community, hence it would not be determined that active

surveillance system was in place in the communities.

Recommendation

A. Monitoring Indicators for WASH behaviour outcome, diarrhoea and dehydration

Indicators for WASH behaviour outcome are broadly covered under 3 domains: Water, Sanitation and Hygiene. This indicator will measure impact resulting in reduction of diarrheal illnesses.

Indicators for home based care and preventive measures against diarrhoea will contribute in control of diarrheal diseases and prevent complications and death.

WASH behaviour change indicators are more appropriate for use than prevalence of diarrheal disease because reduction in diarrhoea prevalence can be due to multiple factors and rate of reduction in the project area cannot be ascertained without a reliable disease surveillance system in place.

Hygiene Content Area Indicator

Indicators

Use of Clean Water 1. % of households practicing correct use of recommended household water treatment technologies

2. % of households storing treated water in clean storage containers

Hand Washing with Soap

at Critical Moments

3. % of respondents who know at least 3 critical moments for hand washing.

4. % of households who know all critical moments for hand washing.

5. % of households with soap and water at a hand washing station inside or within 10 paces of latrines.

6. % of households with soap or locally available cleansing agent and water anywhere in the house.

Use of Sanitary

Facilities for the Disposal of

Human Excreta

7. % of household with children < 5 years old whose faeces were disposed of safely.

Use of prevention measures against diarrhoeal illness

8. % of household who know all danger signs of severe dehydration during diarrheal illness.

9. % of household who know all measures against diarrheal illness.

B. Hygiene Promotional Activities

It is recommended to use community engagement approach as the main approach for Hygiene promotion. Strong community participation and appropriateness of hygiene promotion messages are known to be the key factors to enable hygiene behaviour changes.

Hygiene promotion activities could be conducted with facilitation through community organizers who are first trained in community engagement approach for WASH. Community members once oriented can become volunteer facilitators or community hygiene promoters, whilst they are monitored by community organizer and UPOs. WATSAN committee should be oriented on good hygiene practices and should be involved in hygiene promotion activities in the community.

Cultural group formation to perform street drama at the community on hygiene promotion; School hygiene club formation to promote interactive hygiene sessions in school; women or caretakers group formation to conduct courtyard hygiene promotion meeting etc are recommended as key activities for hygiene promotion.

Appropriate hygiene promotion materials and training material should be developed to target community level participants. All IEC materials should be more pictorial and adapted to local contexts. Flipchart should be developed and distributed to community organizer and community volunteer trainers.

Table below shows recommended activities to achieve outcome 3 of resilience indicator:

Outcome 3:

% of HHs in target community that can demonstrate good hygiene and sanitation practices, including in event of disaster (cyclone or flood)

Activities:

3.1.1.1      WASH community engagement training for trainers (community organizers, volunteers and branch staffs) by BDRCS/BRC technical staffs.

3.1.1.2      WASH community engagement workshop with participants from the community

3.1.1.3 Development of community level WASH awareness/training materials: Flipcharts, Brochure and Pamphlets.

3.1.1.4      Workshop with union and Upazilla WATSAN Committee and concern stakeholders on water, sanitation and hygiene practices and measures against diarrheal illnesses.

3.1.1.5     Form and conduct mothers and caretakers groups courtyard awareness sessions on water, sanitation and hygiene practices and measures against diarrheal illness

3.1.1.6      School sanitation and hygiene educational and interactive session by community organizer to create awareness on WASH practices.

3.1.1.7 Create school hygiene clubs and facilitate hygiene promotion session in the school using peer to peer approach, through facilitation by community organizers.

3.1.1.8 Form a cultural group among community volunteers and organize street drama to create awareness on WASH practices to stop open field defecation, to demonstrate and promote hand

washing.

3.1.1.9 Organize WASH awareness events on key dates such as World Water Day and Global Hand washing Day etc

3.1.1.10 Distribute IEC material and hygiene kit during community workshops, school and caretakers group sessions and key events.

Key messages for hygiene promotion:

Critical Hand washing

Use of clean water

Use of clean water storage

Stop open defecation- waste disposal in safe places

Danger signs of severe dehydration

Appropriate measures against diarrheal illness

C. Linking WASH with livelihood

One of the major issues identified in this assessment is that the poorest household in the community

cannot afford to purchase soap every month. In order to have sustained hygienic behaviour change

such as hand washing with water and soap, households must have soap and water at all times. This

may be possible if poorest households are provided with some financial support. Hence a detailed

livelihood assessment of these communities would help to link WASH/ hygiene behaviour with

livelihood and an appropriate process could be recommended for the poorest households in the

community, to enable them to practices good hygiene.

D. Monitoring and Evaluation plan outline

Baseline assessment of hygiene practices along with water and sanitation to be conducted in all 26

communities to finalize baseline indicators for the programme.

Project management plan with activities, yearly targets based on baseline assessment findings

from all the communities.

Strengthening of WATSAN committee to increase their involvement and support in monitoring of

WATSAN and hygiene promotion activities in the communities.

Quarterly narrative report submission to update on activities as per project log frame.

Mid- term review of the programme to assess progress against the programme objectives.

Final programme review to measure the impact of all interventions.