Sanitation and Hygiene Education Prove their Power

More than two million people die every year of water-related diseases, most of them children. Water and sanitation coverage levels in Ethiopia are among the lowest in the world. According to the UN Children’s Fund (UNICEF), only 31 percent of households have access to safe water, and just 18 percent of households have access to sanitation facilities. Diseases related to inadequate water supply, little hygiene, and poor sanitation in rural areas have been directly connected to as much as 85 percent of total mortalities. Compared to a child in the United States, a child in Ethiopia is fifteen times more likely to die before his or her fifth birthday.

While less glamorous than providing safe water, sanitation and hygiene education are crucial to reducing diseases in the world. Adequate sanitation is a basic human right that safeguards health and human dignity, yet two in five people—approximately 2.6 billion—lack the security and dignity of a simple toilet. Numerous studies have shown—and the Hosanna Project has confirmed—that improvements in sanitation and hygiene practices can significantly reduce disease incidence, even without increased safe water access.

In 2007, Lifewater International began a twenty-two-month sanitation and hygiene pilot project in ten rural communities near the town of Hosanna, Ethiopia. The Hosanna region is part of what the Ethiopian government has designated as “safety net” areas whose basic infrastructure requires urgent attention.

Girl in Hosanna, Ethiopia, washes her hands.

The Hosanna Project confirmed that improvements in sanitation and hygiene practices can significantly reduce disease incidence even  without increased access to safe water.

As a first step, DASSC worked with local government health workers to conduct a baseline survey. The baseline survey confirmed the great need for sanitation facilities and hygiene education: 43 percent of young children suffered acute watery diarrhea, 40 percent of families had no latrine at all, only 26 percent of individuals surveyed washed their hands after defecating, and only 12 percent washed their hands with soap or ash. Amanuel Shiferaw, project coordinator for Hosanna Project One, said, “The baseline survey indicated that all things were not comfortable . . . The government health extension workers had been working for more than ten years, but adequate latrine coverage was only 30 percent. The communities were not clean and attractive . . . In some cases, people only washed their bodies every two months. There was almost no handwashing.”

The next step was to initiate a training "wave."

The next step was to initiate a training “wave,” beginning with Lifewater staff and volunteer trainers and extending into the ten kebeles. Utilizing small teams of qualified North American volunteers, Lifewater trained local project staff and key community leaders (e.g., school directors, teachers, government workers, and kebele managers) in critical topics, including community health through hygiene, WASH promotion, and latrine design and construction. Course facilitators emphasized participatory training methodologies in all lessons. Participants learned how to conduct focus discussions, community mapping, behavioral change trials, and pocket charts. Over the course of the project, Lifewater led four training courses to twenty-five individuals.

As they learned through Lifewater training courses, community leaders began initiating change in their spheres of influence.

Consulted in every step of the process, the Ethiopian government fully embraced the Hosanna Project. The government health workers trained by Lifewater were motivated to focus specifically on WASH issues, which is just one of sixteen health issues for which they are responsible. They also learned to utilize participatory methodologies to train their communities. Zerihun Hailu, who oversaw the project for DASSC at a national level, explained, “The Hosanna project has even changed the government health extension workers. They all have had a bit of training, but Lifewater curriculum teaches them how to approach the communities. That makes all the difference.”

School directors and teachers began mobilizing student WASH clubs to educate students and their families, clean school compounds, and construct school latrines and handwashing stations. Many schools painted WASH messages on their walls, such as “Sanitation is Life Insurance.”

Because they know their students well, teachers tailored lessons to specific needs. For example, Zauditu, a teacher and WASH club coordinator at Hacmura Primary School, said, “I talk openly with the girls about sanitation, about their monthly periods. I teach them to wash and keep clean and tell them that [with the new latrines] there is no need to stay home during their menstruation . . . I have seen them changed by what we teach.” A teacher at the Sundusa School said, “We are teaching one health session per week. It is not boring because there is drama and singing and everyone is participating. It is different than how we teach other things where we are the only ones teaching. I think it is good because if you just say, ‘you have to do this,’ I don’t think they will do it.”

Together with project and government health promoters, kebele managers and other community leaders began efforts among local families. For the first two months of the project between ten and twenty households were selected from each of the ten communities to serve as “model households.” Amanuel explained, “First we simply observed their behavior, then we asked them about possible solutions to risky health practices we saw. Then we made sure they replaced risky behaviors with healthy ones. We observed the changes, addressed ongoing problems, and then used the model households to inspire others to change.”

In addition, the project coordinator and health promoters formed sanitation committees to oversee sanitation education and latrine construction among families. To destigmatize discussion about sanitation, they intentionally gave these committees a provocative name: “chiro committees” (“feces” committees). Amanuel said, “The best thing we did was to teach people to use the word for ‘feces’ in their local language: chiro. Before the training, they would not even say that word. During the training we named chiro committees that were responsible for making sure people had good latrines. In the project area we named more than 50 chiro committees so that every home was visited. Now the people say chiro without problem.” A local community member corroborated, “We used to call feces shuma, which does not carry shame. Now we call it chiro, which is a word that makes you hate it and not want to see it.”

A major issue that the chiro committees faced was the very real danger of latrine pit collapse. Amanuel described the problem and its solution:

“The way the government designed latrines in this area was very difficult. It was too expensive and too deep. The large pits would sometimes collapse—the soil here often does this. People were not happy and would never again build a latrine . . . Latrines were considered dangerous for children. Many families would not let their children use them, so children just defecated in the open . . . But Lifewater training taught them to build latrines that are two-to-four meters deep and have sloping sides to prevent collapse. This is easier for them.”

Another aspect of sanitation education was teaching families that, when properly handled, waste can be used as fertilizer. The chiro committees taught families to move their latrines after one year and plant trees or crops on the old site. “At first they didn’t want to believe us,” said Amanuel. “People refused to accept that. But then we planted trees on top of the compost and another tree away from the compost. The one on the compost grew much better. Now most people are convinced.”

The results of the Hosanna Project’s multi-pronged promotion strategy are outstanding. Innovatively utilizing their own labor and resources, individual families constructed 3,335 new latrines. A local leader said, “Where would you like to go? You can go to any home in our community and you will see very clean grounds and good latrines.” Latrines were also constructed at ten schools, with separate facilities for girls, boys, and teachers. School administrators report that absenteeism is down and enthusiasm for WASH activities remains high. The government supervisor for six schools in the region said, “Of all the schools I supervise, the quality of these two schools [in the project area] is the best. These are model schools that will teach the others. Thank you to the community and to the teachers for the good work.”

According to government surveys, the independent baseline survey, and the final project evaluation, the Hosanna Project boosted latrine coverage in the project area from 60.9 percent to 97.2 percent. Not reflected in these numbers is the significant improvements made in 5,390 old latrines, many of which had been counted in the baseline survey but were deemed inadequate.

Handwashing, an important hygiene behavior, increased dramatically as a result of the project. In the final evaluation, 98.4 percent of respondents answered that they wash their hands at specific appropriate times (i.e., after using the latrine or tending to children’s sanitation needs, before preparing food, and before eating). In the baseline survey, only 26 percent of those asked indicated that they washed their hands at the same specific times. Handwashing with soap, another proven method in mitigating health risks, increased by at least 150 percent.

Handwashing, an important hygiene behavior, increased dramatically.

The local government health offices responsible for monitoring public health reported that acute watery diarrhea, which had been the number two health risk to children dropped completely out of the top ten. In one survey conducted at the project’s conclusion, only 16 of 396 families with children under five years old had an incidence of diarrhea in the past two weeks (4 percent). In the baseline survey, the number was 63 (43 percent).

One kebele, Bobicho, achieved 100 percent latrine coverage and was declared by the Ethiopian government as the nation’s second “Open Defecation Free” community. This honor resulted in national media coverage and interest in replicating this success in other communities.

Another notable result of the project is improved local capacity. During the project, Lifewater and DASSC worked intensively to build initiative, confidence, and skills at all levels. The project coordinator himself learned about good community development. He shared, “[Before working with Lifewater and DASSC] I was working on a different latrine project in one kebele. We gave out more than one thousand latrine slabs but we did not do the sanitation training well enough. At that time even I myself was not changed. We would pile information on them. Go! Go! Go! We just wanted to get it done. When we went back, we found out that many people had broken up the slabs to get the metal. With Lifewater training, it was very interesting, because I learned that the most important thing is to get the people involved.”

In the course of the project, Amanuel learned to facilitate dialogue between community members and between communities and project staff. These efforts fostered a collaborative environment where communities took full ownership of the solutions offered. Communities themselves came up with many of the initiatives that were employed to make such significant improvements to community health. Amanuel said, “I like the focus groups. We give the people a simple direction and then we follow them. We stay quiet and let them lead. One mother told me, ‘The educated ones always guide me, but you are following what I say. This is a new thing. Thank you.’” This type of education gave people who have often experienced domination newfound freedom and confidence.

The church was an important aspect of the Hosanna Project. In the project area 90 percent of the people describe themselves as Christian. The positive relationship between the local people and the Mekane Yesus Church facilitated project efforts. Zerihun explained, “Because we are affiliated with a church that has a long history in the community, it is easy for us to mobilize the community. We have a closer relationship with the community than other NGOs.” In addition, Lifewater’s curriculum resonated with the people. “When we use the Word of God to teach sanitation, they respond very well,” said Amanuel, “especially when we would tell them about Deuteronomy 23:12-13 [“You shall have a designated area outside the camp to which you shall go. With your utinsels you shall have a trowel; when you relieve yourself outside, you shall dig a hole with it and then cover up your excrement.”].”

While glad for their greatly improved health, confidence, and motivation to work together, community members are anxious to add to their health their gains with safe water. Aniya Jekebo, a member of a model household, said, “We are free from disease. We had no knowledge about this hygiene and sanitation. I thank my God for this. Everything is clean. Now we need water.” Model household owner Adabe Erdolo said, “Now we have latrines, we have clean compound . . . no more diseases. But we still have the problem of water. We have a shortage of water.”

They are anxious to add to their health gains with safe water.

Witnessing the overwhelming community initiative, Lifewater is eager to respond to these requests for safe water. Funding has been obtained for one kebele, and Lifewater is actively seeking additional funds to help all ten kebeles gain reliable, accessible safe water.

Other opportunities for the project area include increased access to soap. Future projects might consider microfinance and/or training for small scale soap fabrication and distribution at the community level. An area of education requiring more attention is separating animals from living quarters. Project coordinator Amanuel Shiferaw said, “The hardest unsafe practice to change in my area is separating the animals and the people. People do not want to live apart from their animals.”

Efforts are already being taken to replicate the success of the Hosanna Project in both neighboring communities and in communities nationwide. Lifewater hopes that future funding will enable them to encourage these efforts and help multiply the benefits on a much larger scale.

In sum, the Hosanna Project was a remarkable success that should be replicated. Of particular note are the improvements made in community health through sanitation and hygiene education despite the lack of safe water. These strides prove the communities’ commitment to working to improve their well being and their capacity to properly use and maintain resources that contribute to their health. Lifewater is confident that, with the strong foundation of adequate sanitation and effective hygiene, the ten communities of the Hosanna Project will be good stewards of safe water systems when they are installed.

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