as safer hygienic behaviour. '7

In May 1993, the WHO RegionalOffice for South-east Asia held aninformal consultation on hygiene andsanitation promotion. Faced with theever-present problem of inadequatesanitation - indicated by discouraginglatrine-coverage figures, particularlyin densely populated South-east Asia- the meeting conceded that ExternalSupport Agencies (ESA) should redi-rect their priorities, and aim for 'hy-giene promotion for all', and 'fu IIlatrine coverage for high-risk popula-tions',8 and not necessarily 'for all'.This meeting further agreed that pitlatrines, or ventilated pit latrines andequivalent or superior technologies,are not absolute requirements, eitherfor the safe disposal of human excreta,or for adequate hygiene.

It concluded that 'Human-excretadisposal, as well as improvements inhygiene behaviour, must begin withthe improvement of local practices, andcontinue with the adoption of a rangeof improved, simple, and ]ocally af-

Key indicators - local and globalThe PROWWESS programme (Promotion of the Role of Women in Water andEnvironmental Sanitation Services) was launched by UNDP (United NationsDevelopment Programme) in 1983 to demonstrate how women can be involved;the benefits they and their communities will gain; and how this experience canbe replicated. PROWWESS - and subsequent experiments on severalcontinents - have helped develop a framework for evaluating progress towardsthree major objectives in water and sanitation programmes: sustainability,effective uses, and replicability. The most important element., help to identifykey indicators, and more detailed, measurable sub-indicators. For example, thehygienic use of water is a key indicator of effective use; it can be evaluated bystudying the quality of domestic water, water transport, and storage practices,and site and home cleanliness; and by examining personal-hygiene practices.

The global experience of the PROWWESS framework reflects certainpatterns: its broad objectives have relevance, while specific indicators varyaccording to context. For example, cost recovery may be important in one settingwhile, elsewhere, a tiered maintenance system may be centra] to sustainabi]ity.Communities will find indicators important to their own ]ocal situations (suchas guinea-worm reduction, or easier access to a latrine), and the relativeimportance of these will vary over time. At the beginning of a project, thenumber of water sources to be improved may be the priority. Later, it may bethe number of latrines being built. Gender differences can also influence thechosen indicators of success: women are more likely than men to be concernedwith both the health of their children, and with environmental hygiene.

Communities and project staff may need their own separate indicators;research proves that communities can develop and select the indicators whichthey consider important, and can use them effectively. Project objectives mustbe clear and specific, and project managers need to understand and support thisculture of participatory evaluation. 'One of the biggest challenges of theparticipatory approach ... is to achieve a balance between imposed blueprints,and a total lack of structure ... field experience has shown that this frameworkof indicators strikes a reasonable balance between these two extremes'.9

Step by stepIn the previous article, the writersdescribe how recent developments inhygiene-behaviour research have in-cluded the identification of key indica-tors for sanitation evaluation. In 1992,research into identifying key aspectsof hygiene behaviour - whose modifi-cation would help in the control ofdiarrhoeal diseases - reiterated that,'To judge whether programmes arehaving a health impact, it is acceptableto rely on such intermediate indicators

Indicators for sanitation - yardsticksfor cleanliness?by Astier Almedom and Ashoke ChatterjeeFull latrine coverage and exclusive latrine usehave been promoted widely as the bestindicators for sanitation. But for many ruralpopulations, latrines are either non-existent, ornot in use. One project is building on grassrootsresearch to develop simple, effective indicatorsto prepare the ground for step-by-stepimprovements in excreta disposal.

FOR THE LAST two years, a projectcarried out by the ODA-funded Envi-ronmental Health Programme (EHP)at the London Schoo] of Hygiene andTropical Medicine, has been develop-ing simple and effective indicators forevaluating sanitation. Using the con-clusions of the EHP-convened 199]workshop on measuring hygiene be-haviour as starting points,I,2 a fieldmanual for project staff is beingdeveloped,3 This article charts theproject's progress, focusing on sanita-tion-related behaviour, the methodsused for assessment, and the indicatorsdeveloped.

A good indicator is one which is notonly measurable, but also easy tomeasure; and effective in getting to theheart of the problem. When usinghygiene-behaviour indicators, measure-ment is not always easy: there is nosingle formula which can be used toassess particular hygiene behaviour oractivities, so a mix of appropriatemethods and tools is often called for.

Bearing this in mind, the EHPcarried out a series of field-trials in theTanzanian regions of Siaya and Do-doma, and in central and southernEthiopia; testing the various methodsand tools available, selected fromapplied anthropology, and some parti-cipatory, techniques.4,5 The trials havemade existing methods and tools formeasuring hygiene behaviour acces-sible to field-level project staff, and,secondly, they have helped to identifysome key indicators for evaluatingsanitation (and water supply - seearticle by A]medom in VoLl3, No.2).Several NGOs active in the water-supply and sanitation sectors havealready contributed to this work,6 andthere are plans fot more collaborationsin the field testing of the HEP, in thenear future.

6 WATERLINES VOL.13 NO.3 JANUARY 1995

viewers then found it easy to ask thevillagers why there were no latrines,and to find out what the adults usedas alternatives.

Female project staff, known to thevillagers, and who knew about localcustoms and social norms, deployedthese techniques successfully. Anyonewishing to carry out hygiene evalu-ations must be familiar with the areaand the people, and should have beentrained in the use of appropriatemethods and tools; the shorter the timeavailable, the more knowledgeable theevaluators need to be.

ing; careful planning and the adoptionof unobtrusive and sensitive investiga-tive techniques are called for.

The EHP team tackled this issue byusing direct observations and informalinterviewing methods and tools (seeFigures I and 2). When investigatinglatrine availability and use, for exam-ple, the questions focused on infantsand young children. Mothers/carerswere asked whether young childrenwere 'able to use the latrine', ratherthan 'is there a latrine?' and 'is it inuse?' The woman's reply was, almostinvariably, 'but we do not have alatrine', where latrines were not avail-able. Once past this hurdle, the inter-

c~ Main findings

Q)

If ~ Sanitation-related behaviour and ac-.., Iv .g,j tivities varied between cultures.

'/( 1/,' ~ Among the mainly Christian Luo ofVillagers agreed that this picture western Kenya, disposal of children'sdepicted 'bad behaviour', common in faeces by digging and burying wasthe rainy season. found to be common practice, regard-

less of whether or not mothers/carershad access to latrines. Each infant wastrained to defecate in a speciallydesignated place, and to tell his or hermother/carer, so that she could disposeof the faeces.

Adults did not always use a latrine,either because it did not provide thebasic requirements of privacy andconvenience, or because it was not a'real' latrine, being one of the 'chief'slatrines', constructed during or aftercholera epidemics, upon edicts fromthe chief that every household shouldhave one. Such latrines usually lookedlike latrines from the outside, but oftenconsisted of very shallow pits, or nopits at all. Mpreover, universal latrine

fordable options.' An incremental ap-proach to sanitation promotion wasendorsed, using the imagery of a'sanitation ladder', whereby step-by-step improvements in excreta disposalwere to be encouraged and built upon,rather than pushing for the immediateimplementation of radical changes.

Methods and toolsEHP staff conducted assessments ofthe sanitation-related hygiene behavi-our and activities within three ruralpopulations in East Africa: the Luo ofwestern Kenya and, in central Tanza-nia, the Rangi, and the Gogo. The Luoare predominantly Christian subsis-tence farmers, the Rangi are Muslimsubsistence farmers, and the Gogo are

. semi-pastoral followers of both Chris-tianity and the traditional religion.

Table I outlines the EHP research-ers' methods and tools. They madedetailed descriptions of these andsummarized the results, primarily foruse by the project staff who collabo-rated in the design and execution of thefield studies. It was argued that it is thechoice and combination of methodsand tools that produces valid results,and not any single method or tool.4•8

This is echoed by experiences fromIndia, where PROWWESS and othertools for project evaluation have beenin use for some time (see box).

Sanitation-related behaviour is diffi-cult to investigate, especially when thetime allowed for the study is a matterof weeks, and not months, or at least ayear. The topic does not lend itself tocasual conversation or direct question-

Table 1. Methods for assessing sanitation-related hygiene behaviour and activities

Method/tool Materials used Hygiene behaviour, activities, and features

Structured observations

Semi-structured (open)interviews

Picture-initiated focus-group discussions

Mapping

Three-pile sorting

Pocket-chart

A check-list or spot-check observation schedule(see Figure 1); notebooks and pens.

A semi-structured interview schedule (see Figure2); notebooks and pens.

Selected pictures to introduce the topic and tostimulate discussion; notebooks and pens.

Local materials such as sticks (for sketching on theground), stones and leaves (for marking differentfeatures); notebooks and pens; flip-charts andmarker pens.

A set of 16 pictures with duplicates for use by upto four different groups at the same time; notebooksand pens; flip-charts and marker pens.

A piece of canvas material (1 metre2) withpolythene pockets sewn on; pictures depictingdifferent variables to go in the pockets along the toprow and down the first column; square pieces ofpaper to cover the empty pockets; colour-codedvoting cards; notebooks and pens.

Defecation sites, disposal of young children's faeces,faecal contamination of domestic and public areas.

Defecation sites, disposal of children's faeces,handwashing before handling food, eating andfeeding; after handling children's faeces, afterdefecation, after cleaning children's bottoms, use ofcleansing materials. Mothers'/carers' perceptions ofdiarrhoeal illness, its causes and its management.

Choices of defecation sites, feasibility/practicality ofhandwashing after defecation; after handling children'sfaeces, or after cleaning children's bottoms.

Location of defecation sites, social taboos regardingthe sharing of latrines, feasibility or practicality ofhandwashing.

Local beliefs, perceptions and attitutes towards 'good'and 'bad' hygiene behaviour; reasons why certainbehaviour and activities are perceived to be 'good','bad', or 'in-between'.

Types of sanitation facility currently in use versusfacilities people aspire to have and to use; locallydefined criteria of latrine usability (e.g. privacy,convenience, soundness of structure).

WATERLINES VOL.13 NO.3 JANUARY 1995 7

Figure J. A spot-check observation schedule.

Usafi wa mazingira (Environmental sanitation)1. Kuna dalili zozote za uchafuzi kwa kinyesi? Is there evidence of faecal

contamination?(a) Kando ya barabara? Along the roads?(b) Kando ya njia za miguu? Along the footpaths?(c) Karibu na chanzo cha maji? Near the water source?(d) Kwenye/karibu na shambani? In/near the fields/shambas?(e) Kwenye mazingira ya nyumbani? Outside the houses?(f) Ndani ya nyumba? Inside the houses?

2. Uchafuzi gani ulionekana? What contamination was observed?(a) Kinyesi cha watoto Infants'/young children's faeces(b) Kinyesi cha watu wazima Adults' faeces .(c) Kinyesi cha ngombe na/wanyama mengine -

mahali pa kuzaliana inzi Cow dung and/or other animalfaeces - breeding places for flies

(d) Mengineyo Other3. Je wakati wa 'Matembezi ya Afya' ulimwona mtu yeyote anakunya?

(NanilWapi/Elezea)Did you see anyone defecating during this 'health walk'?"(Who? Where? Describe).

4. Kaya ngapi ulizotembelea zenye vyoo?How many of the houses you visited have a latrine?

5. Choo kimejengwa wapi? Where is the latrine located?(Toa sababu ikiwezekana) (Indicate reasons why, if possible)(a) Ndani ya mazingira ya nyumba Inside the compound(b) Nje ya mazingira ya nyumba Outside the compound

6. Chunguza choo kilivyo Observe the latrine(a) Ua wake unafaa? Does it have a sound superstructure?(b) Je sakafu ni imara kusimama mtu pale?

Is the ground safe to stand on?(c) Je kina bamba? Does it have a slab?(d) Tundu lake ni salama kutumika kwa watoto?

Is the hole small enough to be safe for children?(e) Je kuna faragha ya kutosha?

Does the latrine provide adequate privacy?(f) Hali nyingine yoyote ya choo? Any other features?

7. Kuna dalili yoyote inayoonyesha kuwa choo kinatumika?Are there signs to show that the latrine is in use?(a) Njia ya kwenda kwenye choo iko wazi?

Is the path leading to it clear?(b) Choo ni safi? Is it clean?(c) Je hakuna harufu? Is it reasonably free of smells?(d) Kuna vifaa vya kujisafisha/kuchambia ndani ya choo? Ni vipi? _

Are there cleansing materials in the vicinity? What are they?(e) Je kuna maji ndani ya choo? Is there water in the vicinity?(f) Je kuna majivu ndani? Is there ash in the vicinity?(g) Dalili zingine zinazoonyesha kuwa kinatumika?

Any other evidence of use?8. Vifaa vya kuoshea mikono vipo karibu kiasi gani na choo (maji na majivu au sabuni)?

How close are handwashing facilities (water and ash or soap) to the latrine?(a) Karibu na choo Next to the latrine(b) Mbali kidogo na choo Within walking distance(c) Ndani ya nyumba Inside the house

Note"This question was difficult for project staff to translate directly, probably because itwas unusual and embarrassing, even though it was not going to be posed to anyoneapart from themselves.

use was often unacceptable, becauseof socio-cultural taboos prohibitingcertain categories of people from shar-ing the same latrine. For example, alatrine located within the courtyard ofa Luo homestead could not be usedby the head of the homestead's in-laws.A breach of this rule was tantamountto 'undressing in front of one's in-laws.'

Nonetheless, despite the limited useof latrines, little or no faecal contami-nation was observed, either in andaround viI/age homes, or on the roads

and footpaths. Digging and buryingwas considered to be an adequatemethod of disposal, and it appeared tobe 'safe', at least in the dry season.The study team recommended thatmore investigation should be doneduring the rainy season.

For the Gogo of central Tanzania,most latrines were 'temporary' pits thatwere destroyed during the rainy season.'Lack of time' was cited as the mainreason for not constructing 'permanent'latrines. In contrast, among theMuslim Rangi, more 'advanced' socio-

economic conditions, including higherlevels of exposure to, and interactionwith, governmental and other organi-zations, contributed to more widespreaduse of better-constructed, 'permanent'latrines. In both cultures, digging andburying was the norm when villagerswere cultivating land away from homeand latrine facilities.

Among the Luo and the Gogo,handwashing after defecation was feltto be impractical, mainly because ofthe lack of easy-to-use and locallyaffordable facilities. For the Rangi,handwashing after defecation, aftercleaning children's bottoms, and/orhandling children's faeces, forms partof their ritual-ablution habits but, foreconomic reasons, the use of soap,ash, or other traditional detergents waslimited. In Tanzania, the idea of usingan appropriately designed, hangingcalabash (kangamhwa or ijanta for theGogo and Rangi, respectively), wasidentified as locally acceptable andusable. In Kenya, the study findingswere used for the modification andfine-tuning of ongoing project activi-ties. In Tanzania, the study resultsprovided baseline data against whichhygiene improvements could be meas-ured, once the study areas had beenprovided with water.

Yardsticks for sanitationThe main indicators for sanitation -developed for East Africa, but likelyto be transferable to other parts of theworld, pending field-testing - are:o Disposal of children's faeces Meas-

uring this indicator involves appro-priate combinations of methods/tools. For example, the field trialsconducted in East Africa includedspot-check observations of thehome surroundings, to look out forfaecal contamination; together withopportunistic, direct observationsof the handling and/or disposal ofchildren's faeces, cleansing of chil-dren's bottoms, and use of cleansingmaterials. These were carried outeasily and unobtrusively. The re-searchers conducted informal, openinterviews with mothers and carers;they held focus-group discussionsand, where applicable, used partici-patory tools to stimulate discussion,to generate data, and to facilitateon-the-spot analysis.

o Handwashing after cleaning in-fants'/young children's bottoms andhandling and/or disposing of chil-dren's faeces was investigatedthrough direct observations, infor-mal interviewing, and group discus-sions with or without participatorytools. Again, this was done without

8 WATERLINES VOL. 13 NO.3 JANUARY 1995

Children need access to easy-to-use, conl'enient - if less than ideal- handwashing facilities.

4. Kama sivyo, wanajisaidia wapi? If not, where do they defecate?

5. Watoto wanapojisaidia, vinyesi vyao unavitupa wapi?How do you dispose of the faeces?

AcknowledgementsA draft of this article was presented anddiscussed at the second meeting of the 'Sanita-tion Working Group' convened by the WHO inSwitzerland (Hilterfingen, 3-5 October, 1994).We are grateful to the discussants, including MrPeter Kolsky, for their helpful comments andsuggestions. We would like to thank Dr KatendeKashaija (LSHTM) for checking the Kiswahili.

ReferencesI. Boot. M. and Cairncross, S. (ed.), Actions

Speak: The study of hygiene hehal'iour in",ater and sani/Ution projects, LSHTM andIRC, The Hague. 1993.

2. Cairncross, S. and Kochar, V. (ed.), Studyinghygiene hehm'iour: Methods, issues andexperiences, Sage, New Delhi, ]994,

3. For further dctails on the forthcomingmanual, Hygiene E,'aluation Procedul"l's(HEPJ, or on the field-tests planned in 1995,contact Astier Almedom.

4. Almedom, A. et ai" 'Siaya hygiene evalu-ation study'. Report to the SHEWAS Projectand the EHP, LSHTM, London, 1994.

5. Almedom, A. et al., 'Dodoma hygieneevaluation study'. Report to WaterAid andthe EHP, LSHTM, London, 1994.

6. CARE (International) in Kenya, the AfricanResearch Utilization Network (ARUNET),and WaterAid (UK) made financial contribu-tions to the field trials.

7. WHO/CWS and COD, 'Improving water andsanitation hygiene behaviours for the reduc-tion of diarrhoeal disease'. Report of aninformal consultation, WHO, Geneva, 1993.

8. 'New directions for hygiene and sanitationpromotion'. Findings of a regional informalconsultation, WHO/CWS and SEARO, NewDelhi, 19-21 May 1993.

9. Narayan, D., 'Participatory evaluation: toolsfor managing change in watcr and sanitation,Technical Paper No. 207, World Bank,Washington DC, 1993,Umri

Age

the purposes of sanitation evaluation,the measurement of the following keyindicators of improved hygiene maybe the only 'sanitation' improvementsfeasible to propose: disposal of chil-dren 's faeces (with or without latrines),and handwashing (with soap, ash, oranother local alternative) at criticaltimes.

These indicators have been used formeasuring/assessing existing hygienebehaviour and activities, and not formeasuring behaviour change; to meas-ure change, previous measurements arerequired, against which present datacan be compared. Follow-up measure-ments would be expected to measurehygiene-behaviourchange .•

Jina: Name: Kijiji Mtaa/Kitongoji:Viliage section:

Habari za asubuhilmchana Good morning/afternoon

1. Habari yako? Watoto wako? Familia yako?How are you and how are the children? Other members of the family?

2. Una watoto wangapi? How many children do you have?

Wasichana WavulanaGirls: Boys: _

Jina Umri JinaName Age Name

3. Je watoto wako wanauwezo wa kujisaidia chooni wenyewe?Are your children able to use the latrine?

ConclusionAssessing hygiene behaviour and ac-tivities is not always easy, but it canbe done by appropriately trained (pref-erably 'on-the-job') fieldworkers. For

embarrassing the villagers, becauseattention was focused on the chil-dren and not on the adults.

The measurement of both categoriesof hygiene behaviour may includesub-indicators relating to physical fea-tures, such as the soundness of a latrinesuperstructure, and the availability ofhandwashing facilities, including waterand ash, mud or soap, where suchfacilities exist.

6. Nani mwingine anatumia choo?Who else uses the latrine?

7. Wewe mwenyewe unatumia choo? Do you use the latrine?

8. Kama hapana, kwa nini? If not, why not?

Figure 2. A semi-structured (open) interview schedule.

Dr Astier Almedom is a medical anthropologistin the Department of Epidemiology andPopulation Sciences, Tropical HealthEpidemiology Unit. at the London School ofHygiene and Tropical Medicine, Keppel Street,London WCIE 7HT, UK. Fax: +4417/6367843.Mr Ashoke Chatterjee is a Senior LeclllrerlTrainer at the National Institute of Desif(n, Paldi.Ahmedabad 380007, India. Fax: +91 79438465.

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