ACF ZIMBABZWE
CHIPINGE BASE
WASH EMERGENCY
UNICEF PROGRAM
Household NFI monitoring Report (PDM)
May 2009
Picture 1
Kits distribution in Chimanimani district
Picture 2
Post distribution monitoring in Chipinge district
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ACF ZIMBABZWE
CHIPINGE BASE
WASH EMERGENCY
UNICEF PROGRAM
TABLE OF CONTENT
1
2
Objectives of the survey ...................................................................................................... 3
Methodology .......................................................................................................................... 3
2.1
2.2
Sampling ....................................................................................................................... 3
Survey............................................................................................................................ 4
3
Results and analysis ............................................................................................................. 5
3.1
Knowledge and practices towards Cholera .............................................................. 5
3.1.1
Knowledge on Cholera disease ......................................................................... 5
3.1.2
Knowledge on Cholera transmission ................................................................ 6
3.1.3
Knowledge on Cholera prevention.................................................................... 6
3.1.4
Action taken in case of Cholera ........................................................................ 7
3.1.5
Hand washing practices ..................................................................................... 7
3.1.6
Use of soap during hand washing .................................................................... 8
3.2
Post distribution monitoring ....................................................................................... 9
4
Conclusion and recommendations ................................................................................... 10
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1
WASH EMERGENCY
UNICEF PROGRAM
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
Methodology
As all HH and villages have been listed, it is easy to realise a random sample from those
lists.
2.1
Sampling
The 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)
0.12
= 96
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:
WARD
CHIP 3
CHIP 16
CHIP 20
CHIP 21
CHIP 24
CHIP 25
CHIP 27
CHIP 28
CHIM 20
CHIM 8
CHIM 5
CHIM 3
CHIM 2
VILLAGES
22
15
14
25
19
21
15
14
14
11
6
7
11
Total
Table 1: cluster distribution
HH
3032
3747
3244
2453
3234
3587
2500
3390
1864
1820
1385
1451
941
32648
Nb cluster
3
4
3
2
3
3
2
3
2
2
1
1
1
30
Nb HH
21
28
21
14
21
21
14
21
14
14
7
7
7
210
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
Survey
The 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 questionnaire
The 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 monitoring
The 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 / analysis
The data are daily entered into an Excel database and analysed.
Training
The team followed half day training (theoretical and on the job training). Methodology
and questionnaires / forms have been tested on the field.
3
Results and analysis
A total of 218 households have been interviewed among them 49 from Chimanimani
district and 169 from Chipinge district.
3.1
Knowledge and practices towards Cholera
Among 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.
GOOD
MEDIUM
BAD
Knowledge on Cholera disease
according to attendance to the session
100%
80%
60%
75%
83%
81%
7%
15%
2%
16%
3%
NO
YES
Grand Total
40%
20%
0%
18%
Graph 1: Comparison of the knowledge on cholera according to the attendance of the session.
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3.1.2
WASH EMERGENCY
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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).
GOOD
MEDIUM
BAD
Knowledge on Cholera Transmission
according to attendance to the session
100%
80%
57%
60%
68%
65%
28%
29%
4%
6%
YES
Grand Total
40%
20%
0%
32%
12%
NO
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.
GOOD
MEDIUM
BAD
Knowledge on Cholera Prevention
according to attendance to the session
100%
80%
50%
71%
65%
27%
31%
8%
2%
4%
NO
YES
Grand Total
60%
40%
20%
0%
42%
Graph 3: Comparison of the knowledge on cholera prevention according to the attendance to the
session.
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3.1.4
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Action taken in case of Cholera
GOOD
MEDIUM
BAD
Action taken in case of Cholera according to the
attendance to the session
100%
80%
60%
77%
85%
83%
7%
13%
2%
14%
3%
NO
YES
Grand Total
40%
20%
0%
17%
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.
YES
NO
HAND WASHING PRACTICES
100%
13%
80%
60%
40%
43%
98%
98%
87%
57%
20%
0%
After toilet
Before eating
Before cooking
After handling
sick people
Graph 5: Time of hand washing practiced by interviewees
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There was no significant difference between answers given by attending interviewees and non
attending ones except for the hand washing after handling sick people:
After handling sick people YES
After handling sick people NO
HAND WASHING PRACTICES
100%
95%
7%
15%
13%
90%
85%
93%
80%
85%
87%
75%
NO
YES
Grand Total
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.
YES
NO
Use of soap when handwashing according to the
attendance to the session
100%
80%
60%
68%
74%
72%
32%
26%
28%
NO
YES
Grand Total
40%
20%
0%
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 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
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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.
Not use
Use of the distributed bucket
Use for
transport
only
25%
39%
1%
34%
Use for
storage
only
Use for
both
transport
and
storage
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:
Storage
covered
and clean
Storage facility status
1%
2%
14%
Storage
covered
not clean
83%
Storage
clean not
covered
Storage
not
covered
and not
clean
Graph 9: Percentage of storage facilities according to their status
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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)
not used
5%
21%
good use
74%
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
results showed higher result than the recommendations given by MoH (0.5mg/L). It appears that
purifying tablets are way too strong for the volume of water to be disinfected. Although WHO is
pinpointing any particular danger to health with the obtained concentration, the smell and the taste of
water may turn people not using these tablets.
4
the
the
not
the
Conclusion and recommendations
Despite 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.
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COMMENTS:
YES/NO
Cholera
transmission
YES/NO
What is
cholera
SOLD / GIFT / EXCHANGE
FOOD / EXCHANGE NFI /
STOLEN
Use for storage
Use for
transport
If not, where
Session attendance
YES/NO
42
HH ref
Bucket in
HH
YES/NO
Clean
Cholera prevention
YES/NO
Covered
SURVEYOR
VILLAGE
HH ref
WARD
DISTRICT
BH water /
If not why
In case of cholera action
GOOD / BAD/ NO
Aquatabs
used
PHHP SESSIONS AND KITS POST DISTRIBUTION MONITORING
YES/NO
HW After HW Before
toilet
eating
< 0.5
0.5-1
1
>1
HW Before
cooking
YES/NO
HW After
handling sick
people
YES/NO
Residual
Use of soap for Use of ashes for
Soap in HH
chlorine
Hand washing
Hand washing
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ANNEXE 1 - POST DISTRIBUTION MONITORING FORM
11/11