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Urban Health Training Module Frontline Workers- Water%2C Sanitation and Hygiene WASH%2C Mission Convergence HUP |
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Urban Water, Sanitation and Hygiene
Health of the Urban Poor (HUP) Programme
Training Module for Frontline Workers
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Prepared By:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi - 110016
Content Development and Design prepared in technical collaboration with:
TARU Leading Edge Pvt. Ltd.
Contributed By:
Merajuddin Ahmed, D. Johnson Rhenius Jeyaseelan, Meeta Jaruhar, Biraja Kabi Satapathy, Anil Kumar
Gupta, Rakesh Kumar, Dr. Himani Tiwari, Shipra Saxena
Special Inputs from:
Department of Health and Family Welfare, Women and Child Development Department , Mission
Convergence, representatives from Water Aid, CURE, FORCE, Action India, Plan-India, Mr B.B.Samanta
HUP TAG member
Illustration & Photo Credits:
TARU Leading Edge Pvt. Ltd.
Health of the Urban Poor
Plan-India &CASP-PLAN
About the Manual
The Health of the Urban Poor is a program facilitating and providing technical
assistance on urban health and health determinants. Water, sanitation and
hygiene (WASH) being key determinants of health, necessitate access of the
urban poor to WASH thus leading to better health outcomes, well-being and
reduced poverty. The HUP works closely with the Ministry of Urban Development
(MoUD), Housing and Poverty Alleviation(HUPA), Health and Family Welfare and
Women and Child Development in health, nutrition, and WASH, and in Delhi
it works closely with Mission Convergence, NCD. As an outcome of technical
assistance on urban WASH a training module on Urban Water, Sanitation and
Hygiene Promotion for the use of urban functionaries and frontline workers has
been developed by HUP in consultation with Mission Convergence.
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Contents
Preface
Message
Abbreviations
Chapter 1
Introduction
1
Chapter 2
An Overview of the Manual
2
2.1 Training Objective
2
2.2 Thematic Areas of Training
2
2.3 Target Audience for the Training
3
2.4 The Training Programme
3
2.5 The Training Schedule for Frontline Workers
3
Chapter 3
Training Sessions
6
Day 1 Session 1 Registration
6
Session 2 Welcoming and Introduction
7
Session 3 Pretesting of Participants on Knowledge of WASH
12
Session 4 Perspective building on WASH
13
Session 5 Safe Drinking Water
20
Session 6 Drinking Water Safety at Source and Point of Use
25
Session 7 Safe Sanitation
29
Session 8 Summing up the learning from the first day
33
Day 2 Session 9 Recap of the first day
34
Session 10 Hygiene Behaviour
35
Session 11 Hand Washing
40
Session 12 Diarrhoea Prevention& Management
43
Session 13 Training Facilitation Methods and Techniques
48
Session 14 Role of ICDS and ASHA/ USHA Workers
52
Session 15 Forward Action Plan
56
Session 16 Administration of KAP and Feedback Questionnaires
57
Session 17 Valedictory
58
Chapter 4
Guidance to Facilitators
59
4.1
Do’s and Don’ts
59
4.2
Potential Trainers or Facilitators Profile
59
Annexure:
Annex 1
Guidelines from various Departments of the Government
61
Annex 2
Knowledge, Attitude and Practice (KAP) Questionnaire (pre training)
64
Annex 3
Hand-out- Safe Drinking Water
67
Annex 4
Hand-out- Chlorination in Drinking Water
69
Annex 5
Hand-out- Safe Sanitation
71
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Annex6
Snakes & Ladders Game
73
Annex 7
Hand-out- Hygiene
74
Annex 8
Hand-out-Hand Washing
75
Annex 9
Hand-out- Diarrhoea Management
77
Annex 10
Training Feedback Questionnaire
78
Tables:
Table 1
Training Schedule
3
Table 2
Registration sheet for training on urban WASH promotion
6
Table 3
Study findings on WASH
15
Table 4
Morbidity trends on water related diseases
23
Table 5
Microbiological water related diseases
23
Table 6
Water Borne Diseases
44
Table 7
Converging roles of Health and ICDS
54
Table A.1
WASH in different Government policies
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Preface
As you know, Mission Convergence, a flagship program of the Delhi government seeks to create a
balance between various government departments, community-based organizations (CBOs), and the
community by ringing in major reforms in governance for the empowerment and upliftment of the
vulnerable population of Delhi. Mission Convergence has re-engineered the process of service delivery
through a unique Public Private Community Partnership (PPCP) to make the system more responsive
to citizens. Thus Mission Convergence is a model of public private partnership (PPP) through which the
government reaches out its welfare schemes to the needy.
In continuation with our previous efforts, we strive to promote safe drinking water, sanitation, and
hygiene among the community especially those living in poor urban settlements, to reduce the
incidences of diseases and related expenses, by creating awareness among them through participation
and improving their lives and livelihoods thereof.
We hope “Urban Water, Sanitation and Hygiene Promotion–A Manual for Frontline Workers” will
help urban health functionaries, frontline workers of various allied departments, nongovernmental
organizations (NGOs), and trainers on urban WASH impart training of various components of urban
WASH and create awareness and also stimulate community participation in keeping the neighbourhood
clean and healthy.
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Message
“Health of the Urban Poor” is being implemented by Population Foundation of India (PFI), New Delhi,
with support from the United States Agency for International Development (USAID). HUP is a Nodal
Technical Agency for providing support on urban health especially the health determinants. It recognizes
that water, sanitation and hygiene (WASH) are key determinants in urban health and envisages that the
urban poor should have safe access to WASH for their improved health and well-being. This manual is
also important because key frontline workers like Accredited Social Health Activists (ASHAs) in urban
areas (in few states referred to as USHA or Urban Social Health Activist) and anganwadi workers will
gain in-depth knowledge on urban WASH. Thus they will be able to pass on important messages to
mothers and children while carrying out their key responsibilities linked to health and nutrition.
This training module is primarily for frontline workers, urban functionaries working in various
departments, and NGOs. I hope they will find the manual useful.
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ADB
ANM
ASHA
BC
BSUP
CBOs
CSS
FGD
GoI
HUP
H& FW
H & UD
ICDS
IHSDP
ILCS
ISSH
JMP
JNNURM
KAP
MAS
MCs
MDG
MO
MoUD
NACs
NGO
NRHM
ABBREVIATIONS
:
Asian Development Bank
:
Auxiliary Nurse Midwife
:
Accredited Social Health Activist
:
Backward Classes
:
Basic Services to the Urban Poor
:
Community Based Organisations
:
Centrally Sponsored Scheme
:
Focus Group Discussion
:
Government of India
:
Health of the Urban Poor
:
Health and Family Welfare (Department)
:
Housing and Urban Development (Department)
:
Integrated Child Development Scheme
:
Integrated Housing and Sum Development Programme
:
Integrated Low Cost Sanitation
:
Interest Subsidy Scheme (for housing)
:
Joint Monitoring Programme
:
Jawaharlal Nehru National Urban Renewal Mission
:
Knowledge, Attitude and Practice
:
Mahila Arogya Samities
:
Municipal Corporations
:
Millennium Development Goal
:
Medical Officer
:
Ministry of Urban Development
:
Notified Area Councils
:
Non Government Organisation
:
National Rural Health Mission
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NUHM
OBC
ORS
PFI
PH
PHED
PPCP
PPP
RAY
RC
RCH
RO
SC
ST
SUHM
TA
THM
TSS
UIDS
UIDSSMT
UIG
UHFWC
ULBs
UNICEF
USAID
USHA
VBD
WASH
W&CD
WHO
:
National Urban Health Mission
:
Other Backward Classes
:
Oral Rehydration Salt
:
Population Foundation of India
:
Physically Handicapped (Differently Abled)
:
Public Health and Engineering Department
:
Public Private Community Partnership
:
Public Private Partnership
:
Rajeev Awaas Yojana
:
Residual Chlorine
:
Reproductive and Child Health
:
Reverse Osmosis
:
Scheduled Caste
:
Scheduled Tribe
:
State Urban Health Mission
:
Technical Assistance
:
Tri-Halo Methane
:
Total Suspended Solids
:
Urban Infrastructure and Development Scheme
:
Infrastructure Development Scheme for Small and Medium Towns
:
Urban Infrastructure and Governance
:
Urban Health and Family Welfare Centre
:
Urban Local Bodies
:
United Nations International Children’s Emergency Fund.
:
United States Agency for International Development
:
Urban Social Health Activist
:
Vector Borne Diseases
:
Water, Sanitation and Hygiene
:
Women and Child Development (Department)
:
World Health Organisation
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CHAPTER 1
INTRODUCTION
Water and sanitation (WATSAN) is one of the primary drivers of public health. As per the World Health
Organisation (WHO), 88 percent of diarrheal disease is attributed to unsafe water supply, inadequate
sanitation, and lack of awareness on hygiene practices. Worldwide, 1.8 million people die every year
from diarrheal diseases (including cholera); 90 percent are children under five, mostly in developing
countries1. In India, about 1,000 under five deaths per day are caused by diarrhea2. About 31 percent
of India’s population (377 million) lives in urban areas3 and among them about 93 million (25 percent
of urban population) live in urban slums4 with inadequate water supply and sanitation provisions and
poor hygiene practices. The urban population in India is heterogeneous, from different socioeconomic
groups, with differential access to urban basic services, and governed by national and state level
policies. The schemes and programs are being implemented to provide basic services in urban areas
by various state government departments and concern urban local bodies (ULBs).
Figure 1.1: The Urban Poor, Determinants of Health and Policies and Guidelines
Socioeconomic
determinants of
health
City population
Urban
poor
National and state specific policies for health
and wellbeing
National and state specific guidelines
Program implementation by states/ULBs
Differential
access to
urban
services
In order to address the issues of urban poverty, health and nutrition, and access to urban basic services
key ministries such as the Ministry of Urban Development (MoUD), Housing and Poverty Alleviation
(HUPA), Health and Family Welfare, Women and Child Development, and their respective state
departments have formulated policies and guidelines at the national and state level (see Annexure 1).
1 http://www.who.int/water_sanitation_health/publications/factsfigures04/en/
2 Progress of Sanitation in India: 2010 Update, World Health Organization and UNICEF, 2010.A national perspective based
on the WHO/ UNICEF Joint Monitoring Programme for Water Supply and Sanitation. Henceforth, Progress of Sanitation
in India.
3 Census 2011 (http://censusindia.gov.in/2011-prov-results/prov_results_paper1_india.html).
4 Estimated slum population in 2011, as per the Report of the Committee on Slum Statistics /Census, National Buildings
Organisation, Ministry of Housing & Poverty Alleviation, Government of India, 2008.
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CHAPTER 2
AN OVERVIEW OF THE MANUAL
This manual focuses on the key components of water, sanitation, and hygiene (WASH), which are the
key determinants of health and well-being. It is designed to train frontline workers (anganwadi workers,
urban ASHA/USHA, HUP frontline workers, etc.) of various departments, ULBs, donor organizations,
NGOs, and CBOs and equip them with appropriate knowledge and skills for better urban WASH
outcomes and contribute in achieving the Millennium Development Goals (MDGs).
INTERNATIONAL COMMITMENT TO WATER AND SANITATION
The United Nations General Assembly (2010) recognized WATSAN as a human right, emphasizing
the need for strengthening the achievements of the Millennium Development Goal ("Halve, by
2015, the proportion of people without sustainable access to safe drinking-water and basic
sanitation").
This manual is to be used for individual understanding, organizational learning, and training frontline
workers. It is expected that this will help to develop clarity and understanding on WASH among the
target audience, who in turn would be able to pass on the same to the concerned communities. The
manual contains both subject knowledge and training components.
This manual has been developed by undertaking a secondary review of the literature and by consulting
HUP and WASH experts at the Project Management Unit (PMU) and states for its appropriateness
to the target audience. Key sector players representing PFI, WaterAid, FORCE, Action India, CURE,
Government of Delhi, Mission Convergence, Ministry of Health and Family Welfare, and Women and
Child Development have contributed to the development of this manual.
Figure 2.1 Safe Hygiene Behaviours
2.1 Training Objectives
The objective of the training is to:
• Strengthen understanding, capacities, and skills on urban
WASH issues.
• Equip trainees to impart knowledge on WASH to their
respective communities/target groups.
• Create ambassadors on WASH at the community level
through the anganwadi workers and urban ASHAs/USHAs.
2.2 Thematic Areas of the Training
• Safe drinking water
• Safe sanitation
• Hygiene behavior
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• Hand washing
• Diarrhea prevention and management
• Skills for conducting training on WASH
2.3 Target Audience for the Training
Frontline workers of Housing and Urban Development (H&UD), Health and Family Welfare (H&FW),
and Women and Child Development (W&CD) departments, donor organizations working on WASH,
NGOs, and CBOs.
2.4 The Training Program
The training program includes a session plan followed by a detailing of each session in terms of the
content and methods. The methods promote participation of the trainees and are action oriented.
Before training it is extremely important that the trainer is prepared with the method and the materials
required for training, and have a good understanding of the key functionaries to be trained. The
delivery of WASH training differs with different key functionaries; hence the trainer should be better
equipped with appropriate knowledge on the same.
The change in knowledge of trainees can be monitored by measuring the knowledge, attitude and
practice (KAP) uptake via a pre and post training questionnaire. This questionnaire being same for pre
and post training sessions once filled by the trainee at the beginning and end of the program can be
compared and the changes in responses recorded.
2.5 TRAINING SCHEDULE FOR FRONTLINE WORKERS OF STATE DEPARTMENTS, DONORS, NGOs, AND
CBOs
Duration: 2 days
Table 2.1: Training Schedule
Day Session
Day 1 Session 1
Session 2
Session 3
Session 4
Time
Topic/ Sub-topic
Methodology
Training material
9:30 am – Training participants Registration
10:00 am
Registration sheets/
diary
10:00 am –
11:00 am
Welcome & introduction Expectation
mapping
Objective articulation (establishing
correlation of the participant’s
expectation with training objectives).
Setting ground rules for conducting
training and forming working
groups of participants for training
facilitation.
Ice-breaker game for
introduction
Flash cards for
expectation mapping.
Participatory discussion
for objective articulation.
Flash cards
White board Marker
pen
Chart papers
Bold marker pen
Adhesive/paper
tape
11:00 am – Tea Break
11:15 am
11:15 am – Administering KAP questionnaire on Response by each KAP questionnaire
11:30 am WASH & training facilitation.
participant on a
questionnaire.
11:30 am – •
1:00 pm
•
•
•
•
Perspective building on WASH
Disease mapping
F Chart
Health pyramid
Potty mapping
Guided
discussion
plenary White board
Marker pen
Chart papers
Bold marker pen
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Day Session Time
Topic/ Sub-topic
Methodology
Training material
1:00 pm– Lunch Break
2:00 pm
Session 5
2:00 pm– Safe Drinking Water (activities/ Game-based
3:00 pm
games and situation analysis)
discussion/
• What is safe drinking water? Presentation/
• Safe sources of dri-*-10nking. guided
• Impact of water quality on discussion
health.
group Chart papers
Bold marker pen
Adhesive/paper
tape
plenary
Chart papers
Bold marker pen
Adhesive/paper
tape
White board marker
pen
Session 6 3:00 pm– Drinking water safety at source and Large group discussion White board marker
4:00 pm
at point of use
pen
• Source protection
• Safe water handling
• Water purification
4:00 pm– Tea Break
4:15 pm
Session 7
4:15 pm– •
5:15 pm
•
•
•
•
Safe sanitation
(Activities/ games and Chart papers
Present status and why?
situation analysis)
Sanitation options.
Economic cost of sanitation.
Myths and doubts about
individual household (IHL)
latrines.
Bold marker pen
Adhesive/paper
tape
White board Marker
pen
• Impact and outcomes of safe
sanitation.
Session 8 5:15 pm– Summing up of Day 1
5:30 pm
Large group discussion White board marker
pen
Day 2 Session 9 9:30 am– Recap
9:45 am
Presentation by selected Chart papers
participants
Bold marker pen
Adhesive/paper
tape
Session 10
9:45 am–
10:45 am
Hygiene
• Food hygiene
• Handwashing
• Nail cutting
Game:
Snakes &Ladders
Large group discussion
Snakes & Ladders
sheet (6 feet x 6 feet
(on a flex sheet) or
an LCD projector
Session 11
10:45 am–
11:45 am
Handwashing
• Handwashing as an important
component of hygiene (in
reference with F-chart).
• Handwashing at critical time.
• Handwashing steps.
Game
Large group discussion
Demonstration of Hand
washing practice by
participants in pairs.
Chart papers
Bold marker pen
Adhesive/paper
tape
White board Marker
pen
Water
11:45 am– Tea Break
12:00 am
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Day Session Time
Topic/ Sub-topic
Methodology
Training material
Session 12 12:00noon– Diarrhea
prevention
1:00 pm
management
and Guided
discussion
plenary White board marker
pen
• Diarrhea as an health issue
arising out of WATSAN problems.
• Prevention measures.
• Management
1:00 pm - Lunch Break
2:00 pm
Session 13 2:00 pm– • Training facilitation methods & Large group discussion
3:00pm
techniques
• Lecture/large group discussion
method.
• Case study method.
• Focused group discussion
method.
• Do’s & Don’ts for facilitating
training.
Session 14
3:00 pm–
4:00 pm
Potential role of AWWs and urban
ASHAs/ USHAsin WASH
• Role of Angawadi workers.
• Role of urban ASHAs/ USHAs.
• Frontline workers of urban
health centres.
Large group iscussion
4 . 0 0 p m – Tea Break
4.15pm
White board marker
pen
Chart papers
Bold marker pen
Adhesive/paper
tape
White board marker
pen
Session 15 4:15 pm– Forward action plan
4:45pm
Large group discussion
Chart paper
Bold marker pen
Adhesive/paper
tape
Session 16 4:45 pm– Administering KAP questionnaire on Response by each KAP questionnaire
5:10 pm
WASH & training facilitation
Training feedback sheet
participant on
questionnaire
a Training feedback
sheet
Session 17 5:10 pm– Valedictory
5:30 pm
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CHAPTER 3
TRAINING SESSIONS
The sessions mentioned in the training schedule are described in the following sections with details on
the subject and the mode of training.
SESSION 1: REGISTRATION
Session 1: Registration of participants (15 minutes)
Registration of the participants should be done on a prescribed format. Registration would entail
capturing basic details of the participants:
• Name
• Organization/Company/Agency Name
• Designation
• Place of posting
• Phone number
• Email ID
Others details can also be included depending on the need of the training facilitating agency. The
registration process should be facilitated swiftly and should be covered within 15 minutes. During this
process, distribution of materials among trainees like notepads, pens, training session plans, folders (if
any), etc., should be conducted.
Table 3.1 : Registration Sheet for Training on Urban WASH Promotion
Sl.No. Name
Organisation/ Designation Place of posting Phone number Email ID
Company/
Agency name
Signature of the Training Coordinator
Date:
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SESSION 2: WELCOME AND INTRODUCTION
Session 2: Welcoming participants, introduction, expectation mapping, objective articulation and
setting the ground rules
(60 minutes)
Session 2 of the training will formally pave the way for the commencement of interaction
between the trainer and the trainees. The objectives of the session are to:
• Formally welcome all the
participants and present
a general overview on the
training.
• Carry out introductions
and ice-breaking exercise.
• Mapping participants’
expectations from the
training.
• Articulating training
objectives in the context
of trainees’ expectations.
• Formulating mutually
agreed upon ground rules
for training facilitation.
As evident from the objectives of the session, the session targets conducting multiple tasks which need
to be covered within an hour. The trainer needs to be careful in managing the task efficiently in the
stipulated time and moderate the discussion accordingly.
The tasks where the trainer needs to take special care in terms of process are:
Introduction with the help of a game: The introduction can be done innovatively to not only help in
introducing the participants but also to break the initial inhibition among participants. These games
act primarily as ice-breakers and help make participants comfortable with one another. There are
many games that can be conducted. Some examples are given in the boxes ahead (Boxes 3.1a, 3.1b,
3.2, 3.3) and you could choose a suitable game for your training from among these:
Box 3.1a: Who am I?
This is a fun-filled game using a set of five flash cards for each person. Ask the participants to
write the name of their favourite animal on one flash card in bold letters. Then on the remaining
three flash cards ask participants to write the most remarkable or liked characteristic of their
favoriteanimal. Below this ask them to put a pet name for their favorite animal. Then ask them to
put up the flashcards with the name of the animal on top and the characteristics below on a wall:
Once everyone has done this, the participants will be asked to introduce themselves in the following
manner:
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Lion
Rabbit
Parrot
Powerful
OR
Royal
Peaceful
OR
Meek
Talkative
Colorful
Strong
Frisky
Cheerful
Sher Khan
Lajo
Mithu
Box 3.1b: Who am I?
I AM A Name of the Characteristic 1, Name of the Characteristic 2, Name of the Characteristic 3,
Name of the Animal. I work in Place of Work as a Designation. My name is _________. Today my pet
name is ___________.
Examples:
I AM A Powerful, Royal and Strong Lion. I work in the Department of Health and Family Welfare as
an ASHA. My name is Ranjana. You can call me by my pet nameSher Khan.
I AM A Playful, Meek and Frisky Rabbit. I work in an NGO as a Coordinator. My name is Amit. Today
my pet name is Lajo.
I AM A Talkative, Colorful and Cheerful Parrot. I work for the Department of Women and Child
Development as an Anganwadi Worker. My name is Shalini. Today my pet name is Mithu.
In any of the sessions, in the event the participants are getting bored, they may be addressed by
their pet names and the others may be asked to identify them accordingly. At the end of the training,
the trainers can enquire as to how many people had characteristics close to the list they mentioned.
OR
Box 3.2: Signature Bingo
The objective of this game is to understand each other’s interests, unknown facts, and funny aspects.
For this game, a sheet with 30 squares will be used as a prop. Each square in the sheet will have a
subject of interest or some unknown facts or some funny aspects printed on it. The participants go
around the room, interact with the participants, and get signatures or names of his or her under the
characteristic or aspect intrinsic to him or her. This is a fun way of getting to know each other and
interacting. In the end, one must be able to get as many signatures and fill each square. One square
may have more than one signature. The participant who completes the last square shouts Bingo
and the game is complete. Then, each participant will be asked to introduce herself/himself and
talk about the other participants from the square describing some particular funny aspect/habit/
nature/interest so that everyone else knows.
The Signature Sheet is given below (Table 3.2):
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Table 3.2: SIGNATURE SHEET
B
I
Speaks three
languages
Not married
N
Loves reading
G
Eat chocolates
daily
O
Washes hands
before and after
meals
Has four cups of
tea while working
Has three kids
Plays the guitar
Doesn’t drink tea Brushes teeth
or coffee
thrice a day
Worked in three
organisations
Has a pet at home Paints
Likes ice cream Loves to sleep
Uses more than
three Sims
Lives in a joint
family
Sings
Vegetarian
Does not like to
exercise
Never flown in a Not afraid of
plane
snakes
Writes poetry
Likes Having
panipuri
Hates Cooking
Does not have a
mobile
Has a car
Does not like
Does not like
listening to music eating fruits
Hates cleaning the
house
OR
Expectation Mapping: Expectation mapping attempts to capture the learning expectations of the
trainees from the training. The mapping will be done through a small exercise (see Box 3.4).
Box 3.3: Introduction in Pairs
For this game, the participant needs to be paired in groups of two. All the groups formed should be
given five minutes to interact amongst themselves so that they can collect information about their
partner on the following:
• Name
• Native place
• Work
• Brief family’s background
• A funny aspect about the partner’s personality
After completing the group’s discussion, each member of the group gives his/her partner’s
introduction. The funny aspect of partner’s personality in the introduction would help in lightening
up the environment and easing any initial inhibitions. This would also help in creating a great degree
of comfort among participants. The trainer must also participate in the game.
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Objective articulation: Once the expectations of the participants are established, the trainer should
move ahead to the objectives of the training.
Box 3.4: Expectation Mapping Exercise
The exercise requires blank flash cards. Each participant should be given two blank flash cards and a
bold marker pen. The trainer should request each participant to write down the two major learning
that they would like or expect to acquire from the training. The participants should be given five
minutes to write their expectations, one on each flash card. The trainees are not required to write
their name on the card.
Once the participants finish writing their
expectation on the flash card, the trainer should
collect it from them. After collecting the flash
cards, the trainer should share the expectations
Category 1
Flash
card
Category 2
Flash
card
Category 3
Flash
card
Category 4
Flash
card
with the trainee group. Here the trainer should
Flash
card
also simultaneously try to categorize the learning
Flash
Flash
card
card
expectations into different categories based on Flash
Flash
card
card
similarities or dissimilarities. The trainer should
utilize his/her analytical skills to differentiate
the different learning aspects documented and
arrange them in a matrix accordingly. Normally, three to four different categories in terms of
learning need to emerge from the exercise. They would be most probably related to:
• WASH definition and conceptual understanding
• Health concerns related to WASH
• Interventions/activities in the area of WASH
• Participant’s role in the context of WASH
The trainer should paste all the flash cards on the wall/chart or paper/board under the different
categories in which they fall in terms of learning needs. This would help the participants clearly
understand the collective learning needs and also the trainer in moving toward the articulation
of collectively agreed objectives for the training. There is also a probability of generating some
expectations which may not have any direct relationship with the training. Here the trainer should
be cautious in not discarding the expectation as irrelevant but park it in a separate category citing
genuine learning concern but outside the training domain.
At the end of the training, the trainer should go back to the expectations listed and analyze whether
the expectations of the participants have been fulfilled.
The trainer needs to utilize his/her interpretation and analytical skills in drawing a parallel between the
fixed objectives of the training and the emerged expectations of the trainees.
The inferred parallel will help involve the trainees to articulate the objective.
This will lead to ownership of objectives of the training by the trainees.
Once the objectives are framed, they should be clearly noted on a chart paper and pasted on the wall
of the training hall.
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Ground rule setting for training moderation: Some ground rules for training moderation should be
fixed in context of:
• Time management for sessions.
• Conduct of trainees during the session.
• Group discussion and debate moderation principles.
• Training material management.
• Participation in training activities.
The rules should be fixed through large group discussion method.
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SESSION 3: PRE-TESTING PARTICIPANT’S KNOWLEDGE ON WASH
Session 3: Administration of the Knowledge, Attitude and Practice (KAP) Questionnaire on WASH
(15 minutes)
The objective of the session is to establish a benchmark in the context of the trainees’ knowledge and
exposure to WASH and training facilitation experience. An objective-based questionnaire would be
administered (Annexure 2) to all the trainees, on which they will register their response. The exercise
should be completed in 10 minutes. On completion, all the questionnaires should be collected by the
trainer.
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SESSION 4: PERSPECTIVE BUILDING ON WASH
Session 4: Perspective Building on WASH
(90 minutes)
Evidence suggests that the living conditions—and therefore the health—of the urban poor are, in
many ways, far worse off than of their rural counterparts1. The most visible face of urban poverty,
microcosms of squalor and deprivation amidst a sea of plenty, is visible in slums2. Urban populations,
especially the urban poor, spend significant portions of their time and income coping with the costs of
substandard service, and are deprived of achieving their full economic and civic potential.
Objectives of the session
• Understand linkages between health and WASH.
• Knowledge about WASH following F-diagram.
• Know about the importance and prioritization of hygiene determinants using the health
pyramid.
• Awareness on present practices of defecation through potty mapping.
Figure 3.1: Safe Hygiene Behaviours
Figure 3.2: Unsafe hygiene behaviours
A guided plenary discussion involving WASH resource persons shall be organized. The resource persons
shall talk briefly on the importance of WASH in day-to-day life and take the group forward by sharing
each sub-section and inviting a discussion from the participants on the same in a step-by-step manner.
The facilitator should ask the participants about their perception regarding health and WASH. Different
connotations will evolve from the group, and then the facilitator will summarize the concept.
1 “Framework for Implementation”, Draft for Discussion, National Urban Health Mission, Urban Health Division, Ministry
of Health and Family Welfare, Government of India, July 2010 (http://mohfw.nic.in/NRHM/Documents/Urban_Health/
UH_Framework_Final.pdf).Henceforth, “Framework for Implementation”.
2 A significant proportion of the urban poor also live outside slums, hence critics argue that focusing interventions in slums
alone risks not reaching the entire urban poor population.
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Perspective building on WASH
A clear link between health and water supply, sanitation and hygiene has been established by the fact
that:
High population density in slums coupled with poor environmental conditions makes the urban poor
more vulnerable to a large number of diseases including vector-borne diseases (VBDs) caused by
inadequate provision of clean water and sanitation, and which are twice as high among the urban
poor compared to other urban dwellers3.
Figure 3.3: Poor environmental hygiene
Inadequate provision of safe
drinking water, improper
disposal of human waste, and
lack of adequate systems for
disposal of sewage and solid
wastes leads to unhealthy and
unhygienic conditions.
Ignorance of personal and
environmental hygiene are the
main causes of a large number
of waterborne diseases
The lack of access to proper sanitation, water supply, knowledge, and practice of hygiene practices can
lead to a number of diseases.
Even in places such as the Integrated Child Development (ICDS) centers/anganwadis where there is
interaction between mothers, children, and the anganwadi workers, lack of clean environment, access
to sanitation, hand washing facility, cleanliness, and food hygiene can lead to health diseases and
mortality.
Unsafe disposal of waste
The lack of knowledge regarding personal
and domestic hygiene, environment and
poor water handling practices contribute
to high morbidity at the community level.
This leads to transmission of diseases
through a fecal-oral path4.
Figure 3.4: Unsafe/ Open disposal of water
Lack of sanitation, unsafe disposal or
storage of waste in/around houses and
streets, may provide habitats for vectors
that cause various infectious diseases
like dengue, chikungunya, malaria,
elephantiasis, brain fever, etc.
3 “Framework for Implementation”.
4 Progress of Sanitation in India.
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Some of the diseases transmitted through the fecal-oral path include bacillary dysentery or diarrhea,
cholera, typhoid, polio, amebiasis, worm infections like giardiasis (dysentery coupled with stomach
cramps), and hepatitis A and E (liver inflammation, jaundice). This path of transmission was identified
by Wagner and Lanoix in 1958 and was termed as the F-diagram (sometimes also referred to as the
F-chart).
Sanitation (primarily access to a sanitary latrine) has a marked impact on the transmission of fecal-oral
diseases through the prevention of the contamination of the environment and watersources, and the
removal of breeding grounds for certain insect vectors (such as Muscasorbens).
A growing body of research suggests household water treatment, safe storage and safe handling of
water at point of use which:
• Dramatically improves microbial water quality.
• Significantly reduces diarrhea.
• Is among the most effective of water, sanitation and health interventions and is highly cost-
effective.
• Can be rapidly deployed and taken up by vulnerable populations.
Improvement in WASH leads to a major reduction in diarrheal diseases. The analysis of one of these
studies5 suggests that improvement in different components of WASH differentially impacts diarrheal
diseases (see Table 3.3).
Table 3.3: Study Findings on WASH
Improvement in Components of WASH
Potential Reduction in Diarrhea (at 95%
Confidence Interval)
Overall hygiene
67%
Sanitation
64%
Water supply
81%
Hand washing practices
58%
Source:http://www.bvsde.ops-oms.org/texcom/nutricion/ref7.pdf
• Health and hygiene are both connected.
• Poor hygiene leads to poor health and diseases.
• By adopting good practices at different points of time for prevention of germs to infect us, we
can prevent diseases and enjoy good health.
5 “Water, Sanitation, and Hygiene Interventions to Reduce Diarrhoea in Less Developed Countries: A Systematic Review and
Meta-analysis, The lancet Infectious Diseases, vol. 5. pp. 42-52, 2005 (http://www.bvsde.ops-oms.org/texcom/nutricion/
ref7.pdf).
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The F-Diagram
Most diseases which result in diarrhea are spread by pathogens (disease causing organisms) found
in human excreta (fecesand urine). The fecal-oral route, in which some of the feces of an infected
individual are transmitted to the mouth of a new host through one of a variety of routes, is by far the
most significant transmission mechanism: it accounts for most diarrhea cases and a large proportion
of intestinal worm infections. This mechanism works through a variety of routes, as shown in Figure
2– the “F” diagram.
Figure3.5: The ‘F’ Diagram
Source: Adapted from WEDC (wedc.lboro.ac.uk/resources/factsheets/FS009_FDI_A3_Poster.pdf).
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One gram of feces can contain the following: 10,000,000 viruses, 1,000,000 bacteria, 1,000 parasite
cysts, and 100 parasite eggs6. The chart (Figure 3.5) illustrates various routes of transmission of
infections from open defecation. The primary carriers of pathogens, as depicted in the figure above
are:
Fluids – This normally happens when feces from open defecation comes in contact with water sources
and contaminates it with pathogens. This usually refers to the water used for drinking or cooking. The
host can either drink contaminated water directly or eat food that has been washed in contaminated
water. For example, in urban piped water supply, during transmission, which gets contaminated with
drainage water when the pipe passes through the drain.
Fields – People defecate outdoors, fields or use fecal material as agricultural fertilizer. Children often
defecate in the yard around a house. This exposes the microorganisms in feces to rainwater, to flies,
and to food—whence it can infect the host when the vegetables are not washed before cooking/eating
or fruits are not washed before eating.
Flies – Flies are the most common carriers of pathogens from human feces. Flies touch down on
feces and transmit the bacteria, protozoa, and viruses in feces to food, water, utensils, and the food
preparation area. Flies act as the transit vehicle for pathogens from feces to consumable items,
primarily food. Flies through their wings, hairy legs, antennae, vomit and defecation pass on the
pathogens wherever they sit.
Fingers –Fingers can become contaminated by unhygienic cleansing practices and pass disease agents
to the new host directly or by contaminating food or water which comes in contact with fingers. If
hands are not washed after a person has defecated.
If hands come into contact with someone else’s feces on the ground (such as when small children are
crawling, or playing, on the ground or when adults clean a child’s faeces)
Indirectly from a person’s hands, if not washed after defecation from food which has been prepared
by them, from food which is eaten with dirty hands, and from cups or other utensils handled by dirty
hands.
Therefore, the primary measure in context of protection from pathogens and infection is by breaking
the transmission chain. The F-Diagram above depicts the barrier in thick dark horizontal lines that can
be created for breaking the transmission chain.
Preventive Measures Figure 3.6: F Chart
The prevention of diseases mentioned earlier is possible by having in place barriers that would block the
path of fecal-oral transmission of diseases. These
barriers are classified into two types: primary
barriers and secondary barriers (see Figure 3.6).
While primary barriers prevent the initial contact
with diseases, the secondary barriers prevent the
ingestion of pathogens by a new person. Access to
adequate and proper means of sanitation, clean
water from the source to the point of use and
good hygienic practices are barriers to diseases
transmitted through the fecal-oral path.
Primary barriers
6 Source: Quoted from WHO, 2008c; Quoted in The Economic Impacts of Inadequate Sanitation in India by WSP (World
Bank), ADB, AusAID, UKAID (www.wsp.org/sites/wsp.org/files/publications/wsp-esi-india.p)
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Improved sanitation infrastructure that restricts open defecation stops transmission of pathogens to
the first three carriers in the primary level, that is, water, field, and flies.
Hygiene practices, primarily handwashing, which washes away pathogens from fingers.
Secondary barrier
Proper water handling and water treatment along with washing hands before and after eating helps as
the secondary barrier in preventing the diseases through the fecal-oral route.
The Health Pyramid
The health pyramid helps identify the importance of different behavior patterns that are useful in
improving hygiene behavior. At the top of the pyramid is life saving behavior, followed by health
improving behavior, and then the aesthetic behavior.
Fig 3.7: The Health Pyramid
Life saving behavior is essential to keep the person
alive. For example, hand washing at critical times,
prevention of water from getting contaminated, safe
disposal of human feces can prevent waterborne
diseases that get transmitted through the fecal-oral
route.
Life Saving
Behavior
Health improving behaviour is important because
they make a person active. For example, bathe
to prevent skin infections, make soak pits to stop
breeding of mosquitoes, brush teeth, etc.
Health
Improving Behavior
Aesthetic behavior is that which makes a person
bright and beautiful. For example, behavior such
as combing of hair or wearing good clothes, anal
Aesthetic Behavior
cleansing with water, rinsing the mouth after meals,
washing hands after eating, burning paper rubbish.
Source: Hygiene Promotion Manual, WaterAid, 1999
Potty Mapping:
Potty mapping is done to understand the existing defecation practices of a community. For this an
existing slum map will be beneficial or, alternatively, a map about a slum will be drawn. The following
are the steps.
The slum in this case is Ramnagar; it has 550 households and 250 households have latrines. There are
about 3,000 people living in the slum, and in Ramnagar they have access to one community toilet, and
that too in a neighboring slum.
Facilitator to guide volunteers to draw on the floor, using plaster of Paris, slum features like lanes,
houses, open spaces, garbage dumps, drains, temples, community toilets, and the like.
Ask the volunteers to sprinkle turmeric powder or yellow rangoli powder at all those spots where open
defecation took place. It should include areas where children and adults defecate, inside or outside
the slum locality. You will soon see the entire slum covered in yellow as children would have defecated
almost everywhere in the open.
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Summing up: The facilitator should stress that the slum boundaries started out with the color white,
indicating clean spaces. Gradually, human activity filled up the spaces with yellow, indicating the
presence of excreta. The excreta, scattered all around, contaminated groundwater. So effectively,
people in the area were drinking water laced with the excreta generated by the slum. The facilitator
should make the message even more hard-hitting by saying: “People here do not drink water, but the
excreta of 3,000 slum residents.”
Fig 3.8: Potty Map
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SESSION 5: SAFE DRINKING WATER
Session 5: Safe Drinking Water
(60 minutes)
The objective of the session would be to:
• Build an understanding on drinking water sources.
• Sensitize trainees on safety issues pertaining to drinking water.
• Educate the trainees on the impact of unsafe water on human health.
Method for session moderation
This session will try to bank upon the experiences of
the trainees related to water supply in urban areas
for initiating a discussion on the topic. Therefore, a
game-based small group discussion/exercise would be
conducted.
Figure 5.1: Tanker water
Box 3.5: Understanding water supply in urban areas
This Essentially, the game would energize the trainees to actively participate in the discussion on
the topic of the session. The game would be in the form of a small drawing competition in which all
the trainees would participate. All the trainees would be given a white chart paper and color sticks/
pencils. The topic of the drawing competition would be “water in the tap”. In this competition, each
trainee would depict in the drawing, their own understanding of how water reaches the tap in their
house. The trainees would be given 15 minutes to draw the picture, after which all the pictures
would be displayed on the walls of the training hall. The trainer would act as the jury of the drawing
competition and judge the three best painting among all. A token prize would be given to all the
three winning trainees (the trainer can decide upon the prize, which can be a set of color boxes or
chocolates, etc.).
The game will set the stage for initiating a discussion on the topic of safe drinking water. Taking cue
from the best three painting of the drawing competition, the trainer should lead the session into a
focus group discussion (FGD)pertaining to the situational analysis of the water supply in urban areas.
For the FGD, the following topics would be taken up for discussion.
Topic 1:Mapping of water sources in urban areas
Topic 2:Water usage (purpose and priority) at household level for day-to-day life
Topic 3:Safety of drinking water usage at ICDS centers and at Urban Health and Family Welfare
Centres (UHFWCs)
Topic 4:Classifying safe and unsafe sources of water and consecutive rationale as what is safe and
what is not?
Topic 5: Safe handling of water for a healthy life
The trainees would be divided into four groups; each group would be given one topic from the
above list for discussion. All the groups would be given 10 minutes for conducting a discussion
within their groups on their respective topics and prepare a presentation on chart paper. Each group
would be required to present their discussion points on the topic.
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The presentation would create a benchmark of the
knowledge/information that the trainees already have
in the context of safe drinking water. This would help
the trainer assimilate information on the subject that is
missing from the presentation and also initiate discussion
on new areas. A hand-out regarding safe drinking water is
given in Annexure 3.
Figure 5.2: A ground level storage tank
The discussion points from the trainer should focus on the
following:
What is Safe Drinking Water?
Drinking water is basic for human survival. However,
in general, all water cannot be deemed fit for human
consumption. Sometimes, water may look dirty and be
foul smelling, or be bad to taste because of chemicals,
physical substances or pathogens (microbiological) in it
which may or may not be visible to the naked eye. Such
water is unsafe for human consumption as it may harm our health. But safe water does not harm the
user. It is free from pathogens, harmful chemicals, and physical substances, pleasant to taste, and
Box 3.6: Drinking water quality typically fall under two categories:
Chemical/physical - Chemical/physical parameters include heavy metals, trace organic compounds,
totalsuspended solids (TSS), and turbidity (the cloudiness or haziness of a fluid caused by individual
particles that are generally invisible to the naked eye, similar to smoke in air). The measurement of
turbidity is a key test of water quality.
Chemical parameters tend to pose more of a chronic health risk through the buildup of heavy
metals although some components like nitrates/nitrites and arsenic can have a more immediate
impact. Physical parameters affect the aesthetics and taste of drinking water and may complicate
the removal of microbial pathogens.
Microbiological - Microbiological parameters include coli form bacteria, E. coli, and specific
pathogenic species of bacteria (such as cholera-causing vibrio cholerae), viruses, and protozoan
parasites. They mainly come from human or animal feces. Microbial pathogenic parameters are
typically of greatest concern because of their immediate health risk.
Therefore “safe” drinking water is water which is free from chemical/physical and microbial
elements, as stated above, which has the potential of inflicting disease on consumption.
usable for domestic purposes. It is important for frontline workers to educate the community on safe
drinking water.
Safe Sources of Drinking Water
A safe drinking water source is one that by the nature of its construction and design adequately
protects the source from outside contamination, particularly fecal matter.
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Box 3.7: Improved Water Technologies
Improved water supply technologies that are more likely to provide safe drinking water as per
guidelines of the World Health Organization (WHO) are:
• Piped water into dwelling, yard or plot
• Public tap or standpipe
• Tube well or borehole
• Protected dug well
• Protected spring
• Rainwater collection
Sources that don’t encourage improved drinking water include:
• Unprotected wells
• Unprotected springs, rivers or ponds
• Vender-provided water
• Bottled water (consequential of limitations in quantity, not quality of water)
• Tanker truck water
Impact of Drinking Water Quality on Health
In order to understand the importance of safe drinking water and its impact on health, it is important
to look at the health hazards that arise from drinking unsafe water.
Box 3.8: Impact of Drinking Water on Health
Seventy to eighty percent of morbidity is related to water contamination, primarily fueled by:
• Unsafe sanitation practices
• Unhygienic environmental conditions
• Ignorance of personal hygiene
It is reported that 94.4 percent of urban households have
access to improved source of drinking water1 and 83 percent
have access to any type of sanitation facility. The coverage is
not reflecting in terms of reduction in burden of diseases. Table
3.4 depicts the health concerns that have risen due to water
contamination.
1 International Institute for Population Sciences (IIPS), “DLHS-3, 2007-08, Fact Sheet India”, Ministry of Health and
Family Welfare, Government of India, and IIPS, Mumbai, 2010.
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Table 3.4: Morbidity Trends of Water-related Diseases
Sr. Disease
1. Diarrhea
Morbidity in Urban India (no. of cases)
2001
2009
9.28 million
11.98 million
2. Malaria
3. Viral Hepatitis
4. Cholera
20.5 million
1.49 lakh
4178
1.56 million
1.24 lakh
5155 (2010)
5. Typhoid
4.90 lakh
10.99 lakh
Water quality deteriorates primarily due to microbiological and chemical contamination. While
the chemical contamination of water supplies can cause serious problems, microbiological
contamination is the largest public health threat, especially in poor communities. When water
sources are contaminated by human and animal feces, waterborne diseases can be transmitted.
The many pathogens that can be present in feces are ingested by humans through drinking and
cooking water.
Pathogens are micro-organisms that can cause disease in humans and fall into three major classes:
Bacteria which are single-celled organisms, typically 1 to 5 μm in size (1000 μm =1mm).
Viruses which are protein-coated genetic material that lack many cell structures, and are much
smaller than bacteria;in most cases 10 to 300 nm (1000 nm = 1μm).
Parasites which are single-celled organisms that invade the intestinal lining of their hosts. The two
main types of parasites are protozoa and helminthes (intestinal worms).
Table 3.5 below depicts the diseases that can occur in humans due to pathogens.
S.No.
1
2
3
4
Table3.5: Microbiological Water-related Diseases*
Category
Example
Waterborne
Diarrheal disease
Cholera
Dysentery
Typhoid
Infectious hepatitis
Water washed
Diarrheal disease
Cholera
Dysentery
Trachoma
Scabies
Skin and eye infections
Acute Respiratory Infections (ARI)
Water based
Schistosomiasis
Guinea worm
Water related
Malaria
Onchocerciasis
Dengue
Fever
Gambian sleeping sickness
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*Adapted from “Table 4. Classification of Water Related and Transmission Routes with sample
diseases from White et al., 1972. An Analysis of the Relationship Between water Accessibility, Use
and Health in Muthara, Kenya by Paul M. Kennedy, Michigan Technology University, 2006.
Chemical contamination of drinking water resources can also seriously damage health, for example,
iron, fluoride, arsenic, and nitrates, etc. Specific filters are needed to decontaminate water from
these impurities.
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SESSION 6: DRINKING WATER SAFETY AT SOURCE AND AT POINT OF USE
Session 6: Drinking Water Safety at Source and at Point of Use
(60 minutes)
The objective of the session is:
• To educate trainees on safety of water sources and safe handling of water.
• To educate trainees on various methods of drinking water treatment at point of use.
Method for session moderationFigure 6.1 : Tubewell
This session targets supply of specific inputs on water
safety issues pertaining to drinking water. Therefore, a
participatory lecture or large group discussion would be the
best method to conduct the session.
The discussion should focus on the following aspects:
• Source protection
• Water transportation/conveyance
• Water handling and protection at home
• Water purification
The trainer should initiate the discussion by asking cue
questions like:
• What can be done to ensure the safety of drinking water?
• What are the different methods that can be adopted to ensure safety?
Based on the reaction of the trainees on the cue questions, the trainer should moderate his/her
discussion on the following areas:
Source Protection
Minimizing contamination of water systems begins with protection at water source. Water sources
should be protected from all forms of contamination, primarily induced by unsafe human practices
(for example, washing at source, waterlogging, open defecation, etc.) especially in slums where
there is no piped water supply, people have to rely on other sources of water such as tube wells and
dugwells.
Families and communities can protect their water supply by:
• Keeping wells covered and installing handpumps.
• Disposing faces and waste water away from any water source used for cooking, drinking and
washing.
• Building latrines at least 15 meters away and downhill from a water source.
• Keeping buckets, ropes, and jars used to collect and store water as clean as possible by storing
them in a clean place.
• Keeping animals away from drinking water sources and family living areas.
• Avoiding the use of pesticides or chemicals anywhere near a water source.
• Sanitary inspection of water sources and water quality testing should be undertaken
periodically.
(A Sanitary inspection is an on-site inspection of a water supply to identify actual and potential
sources of contamination. The physical structure and operation of the system and external
environmental factors, such as latrine location, are evaluated as part of this.)
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Safe Water Handling
Safe Transportation of Water
Even though the source may be safe, water can be contaminated by an individual in many ways. It is
essential to prevent this and hence the following steps need to be practiced while collecting water
at site and when storing it at home:
• Handwash before collecting water daily.
• Container/vessel used for water collection should be washed or cleaned properly.
• Do not dip hands in the water while lifting or carrying the vessel.
• Cover the vessel while carrying it home to avoid dust falling into it.
• Do not fill the water till the brim of the container/vessel to avoid to use hands to take off the
excess water.
Protection at home
Following steps need to be taken at home to protect drinking water from contamination:
• Keep the vessel at a raised position.
• Keep the vessel covered.
• Do not dip hands while taking out water.
• Use of ladle or tap-fitted vessel for taking out water.
• Do not continually top up the water in storage vessels. After each use vessels must be
thoroughly rinsed with potable or treated water.
Figure 6.2: Covered Vessel
Figure 6.3: Use of ladle for safe drinking water
Water Purification at Point of Use
Water from tube wells/dugwells, etc., and from municipal supply systems which are deemed to be of
doubtful quality should be disinfected at home. The reason is that during transmission the municipal
water supply can be contaminated, for example,when pipes pass through drains or develop cracks at
various points. Point of use (POU) water treatment refers to a variety of different water treatment
methods (physical, chemical, and biological) used to improve water quality for an intended use at the
point of consumption instead of at a centralized scale (involving a distribution network).
In order to quickly test the contamination, a hydrogen sulphide (H2S) strip is a potentially useful
tool for screening water sources and drinking water for fecal contamination. However, the results
for bacteriological contamination using H2S strip technique are at best indicative and in case of
contaminant detection one must go the extra mile to a water quality laboratory. The H2S strip test
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checks the most probable number or MPN of coliforms present in the water. It is easy to use and
readily available. The method of testing by the kit involves:
• Dry and sterile media are provided in the screw-capped bottles, which are ready for use.
• Fill the water to be tested in a bottle up to the mark and cap it.
• Shake the bottle gently after five minutes.
• Keep in a warm place, preferably at 30–37 degree celsius, for 24–48 hours.
• Observe for blackening of the contents.
• If it turns black, it is likely that the water is not fit for drinking.
Ready to use medium Fit for drinking Unfit for drinking
Box 3.8: Water Treatment at Point of Use
Water treatment at the point of use, for example, in households or schools, has been found to reduce
diarrhea caused by waterborne pathogens by 30–50 percent. Common point of use treatment
methods include one or a combination of the following methods meant for water purification at
household levels.
Boiling –Bring water to a rolling boil and holding at this temperature for a specified time. This will
kill pathogens effectively (except at high altitudes). A holding period of three to five minutes will
ensure that water is safe, except in situations where contamination with spore-forming bacteria,
fungal, or protozoal cysts or hepatitis virus is suspected, in which case 10 minutes is advised.
Disinfection using chlorine - Chlorine when used correctly will kill all viruses and bacteria, but some
species of protozoa and helminthes are resistant. There are several different sources of chlorine for
home use, in liquid, powder, and tablet form and should be used as directed by the manufacturer.
Please refer to Annexure 4 for chlorination of drinking water.
Figure 6.7: Chlorination
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Water Filters - Commercial low cost filters consist of activated carbon for filtration followed by
programed chlorination for disinfection. This dual approach leads to high quality treated water.
Filters need to be cleaned regularly to avoid becoming reservoirs of microorganisms.
Flocculent Powder - This is a useful method where people use highly turbid water. The flocculent/
disinfectant powder has been proven to remove the vast majority of bacteria, viruses, and protozoa,
even in highly turbid waters. Commercially produced sachets of powder, which act by coagulating
and flocculating sediments in water followed by a timed release of chlorine, are available. The
water is normally stirred for a few minutes, strained, and allowed to stand for a half hour.
UV Disinfection- Ultra-violet rays from the sun are used to inactivate and destroy pathogens present
in water. Solar disinfection (SODIS) was developed in the 1980s to inexpensively disinfect water
used for oral dehydration solutions used to treat diarrhea. Fill transparent plastic bottles (2litres)
with water and expose them to full sunlight for about five hours (if sunny) or two days (if cloudy).
Disinfection occurs by a combination of radiation and thermal treatment.
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SESSION 7: SAFE SANITATION
Session 7: Safe Sanitation
(60 minutes)
The objective of the session would be to:
• Build an understanding on sanitation status in an urban area.
• Sensitize trainees on aspects related to safe sanitation and its implication on health.
• Educate the trainees on intervention required for safe sanitation.
Method for session moderation
Figure 7.1: View of a slum
This session will try to bank upon the experiences of the trainees related to sanitation practices in
urban areas. Therefore, small a group discussion/exercise would be conducted on the following:
Topic 1: Mapping of sanitation practices in an urban area, especially in slum areas (infrastructure and
behavior).
Topic 2: Basic prerequisites for safe sanitary practices.
After the group discussion, through brainstorming and presentation, the key points on sanitation
entailed in Box 3.9will be discussed/presented.
Box 3.9: Understanding Sanitation Practices
The trainees would be divided into four groups; two groups would be given the first topic and the
other two groups would be given the second topic for group work. All the groups would be given 10
minutes for conducting their discussion within the groupand prepare a presentation on chart paper.
Each group would be required to present their discussion points on the topic.
The presentation would build a benchmark of the knowledge/information that the trainees already
have in the context of the sanitation practices they are exposed to. This would form a cue for the
trainer to feed information pertaining to the subject which is missing from the presentation and also
initiate discussion on new areas. The discussion points the trainer needs to focus upon are:
• Understanding sanitation
• Sanitation options
• Economic cost of sanitation
• Impacts and outcome of safe sanitation
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Understanding Sanitation
Sanitation is broadly defined to include management of human excreta, solid waste, and drainage.
The United Nations-World Health Organization Joint Monitoring Programme for Water Supply and
Sanitation defines “improved” sanitation as:
“The means that hygienically separate human excreta from human contact and hence reduces
health risks to humans.”
Figure 7.2: Open Defecation
Inadequate sanitation exposes people to human excreta and thus to disease-causing fecal pathogens
through different transmission pathways. In India, over 80 percent diseases are caused due to
infections transmitted through direct or indirect routes from human waste. Human waste contains
a spectrum of pathogens, and over 50 types of different infections are transmitted through direct
or indirect routes from such waste.
In urban areas, especially where slums are situated, the status of sanitation is an important concern
especially with the fact that:
• About 50 million people in urban India resort to open defecation and 26 percent do not have
any household sanitation arrangements – mostly the urban poor.
• Out of 300 Class-1 cities, about 70 percent have partial sewerage systems and sewage
treatment facilities. Of the total wastewater generated, barely 30 percent is treated before
disposal.
• Waterlogging is a major problem in urban areas, especially in the slums.
• All this contributes to the local environment being unhygienic and increases the risk of human
excreta coming in contact with humans.
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Sanitation Options
Sanitation is broadly defined to include management of human excreta, solid waste, and drainage.
The United Nations-World Health Organization Joint Monitoring Programme for Water Supply and
Sanitation defines “improved” sanitation as:
“The means that hygienically separate human excreta from human contact and hence reduces
health risks to humans.”
Figure 7.2: Open Defecation
Inadequate sanitation exposes people to human excreta and thus to disease-causing fecal pathogens
through different transmission pathways. In India, over 80 percent diseases are caused due to
infections transmitted through direct or indirect routes from human waste. Human waste contains
a spectrum of pathogens, and over 50 types of different infections are transmitted through direct
or indirect routes from such waste.
In urban areas, especially where slums are situated, the status of sanitation is an important concern
especially with the fact that:
About 50 million people in urban India resort to open defecation and 26 percent do not have any
household sanitation arrangements – mostly the urban poor.
Out of 300 Class-1 cities, about 70 percent have
partial sewerage systems and sewage treatment
facilities. Of the total wastewater generated,
barely 30 percent is treated before disposal.
Waterlogging is a major problem in urban areas,
especially in the slums.
All this contributes to the local environment
being unhygienic and increases the risk of human
excreta coming in contact with humans.
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Economic Cost of Sanitation
It is observed that in slum areas people generally defecate in the open and often near the water
source, which contaminates water bodies resulting in even greater infection.
The impact on unsafe sanitation to human health is significant. Unsafe sanitation practices facilitate
transmission of vector-borne diseases, including diarrhea and a range of intestinal worm infections
such as hookworm and roundworm. More importantly, young
children bear a huge part of the burden of disease resulting from
the lack of hygiene. Diarrhea accounts for almost a fifth of all deaths
(or nearly 535,000 annually) among Indian children under five years
(ADB, 2009)1
High and repeated cases of illness, especially diarrheal diseases,
which lead to loss of working days, affect the earning potential of
the affected person and thus economic productivity.
Economic losses due to expenditure on medicines and health care.
The loss due to diseases caused by poor sanitation for children
under 14 years alone in urban areas amounts to Rs 500 crore at
2001 prices (Planning Commission-UNICEF, 20062
The economic toll is also significant in terms of indirect losses such as
water treatment costs, reduced school attendance, inconvenience,
and wastage of time.
Figure 7.4: Disease symptoms
1 ADB- Water for All Series 18; 2009; India’s Sanitation for All: How to make it happen
2 www.urbanindia.nic.in/programme/uwss/NUSP.pdf ( National Urban Sanitation Policy, Ministry of Urban Development,
Government of India
Impact & Outcome Due to Safe Sanitation
Sanitation brings privacy, dignity, equality, and safety for all. While having a toilet is important for
everyone, access to safe, clean toilets is particularly beneficial to women and girls. Freed from the
need to defecate in the open, they no longer have to suffer the indignity of physical and verbal
abuse or humiliation when relieving themselves. Sexual harassment is also a risk for many women
who wait until nightfall and seek the privacy of darkness to relieve themselves. Where improved
sanitation is provided along with better hygiene behavior, real health benefits follow, and these are:
• Lower morbidity and mortality due to diarrhea.
• Better nutrition, reduced stunting, and increased height among children due to reduction in
diarrheal disease.
• Improved learning and retention among school children due to reduction in worms and other
sanitation related diseases.
A hand-out on safe sanitation is placed in Annexure 5.
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SESSION 8: SUMMING UP THE LEARNING FROM THE FIRST DAY
Session 8: Summing up the learning from the first day
This session marks the wrapping up of the first day of work of training.
(15 minutes)
The objective of the session is to reinforce the discussions and learning that have taken place on
the first day.
In a large group discussion method, the trainer should elicit response from the trainees related to
the subjects and topics that were discussed during the training sessions on that day. This will help
generate a summary of responses from the trainees, which should be duly noted on a white board
or chart paper. There is a high probability that the response generated from the trainees would be
in a random pattern, that is, it will not be according to the chronological session order of the day.
Here the trainer’s role will be to take a cue from whatever response that was generated from the
trainees and try to summarize the discussion of the day in a chronological order.
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SESSION 9: RECAP OF THE PREVIOUS DAY
Session 9: Recap of the previous day
(15 minutes)
Recapitulation of the first day of training should be done by a trainee group consisting of five to six
members. The trainee group that recaps should be formed on the first day itself, during session 2 as a
part of setting ground rules for training facilitation.
The trainee group should do the recap with the help of presentation prepared on chart paper. The
trainer should ensure that all group members participate in the recap.
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SESSION 10: HYGIENE BEHAVIOR
Session 10: Hygiene Behavior
(30 minutes)
The objective of the session is to:
• Sensitize the trainees on the importance of hygiene as a crucial component of living a healthy
life.
• To educate trainees on hygienic behavior pertaining to food, personal hygiene, and handwash.
Method of Session Moderation
The session would be moderated with help of a game, followed by a large group discussion. The game
would be used as a platform to energize the participants and also to feed the cues for the discussion
on issues pertaining to hygiene. See Annexure 6 for a full image of the Snakes & Ladders game.
Box 3.10: The Snakes &Ladders Game
The trainer should select five volunteers from the trainee
group to play the game. The game should ideally take
20–30 minutes.
A large dice of cardboard may be kept ready along with
five objects to be used as players. Each volunteer would
be asked to roll the dice and move the objects across
the board, as in the original Snakes &Ladders game.
Whoever wins will be the hero of the day.
Alternatively, the same can be illustrated on a large piece
of cloth. Instead of objects representing players, the
original players can roll the dice and move on the cloth
according to the numbers themselves.
The game will help in identifying basic indicators pertaining to hygiene. Taking cue from this the trainer
should than lead the trainee group into a participator large group discussion on the following:
• What is home hygiene?
• What is personal hygiene?
• What is food hygiene?
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What is Home Hygiene?
The home is an environment where most human activities occur. Home hygiene practice is the sum
total of the practices which are undertaken to protect the family from hygiene-related diseases.
Home hygiene practice is the sum total of all the things we do to break the chain of infection in the
home.
The main home hygiene practices are:
• Food hygiene - safe cooking and storage of food, safe disposal of food waste
• Personal hygiene
• General hygiene (surface cleaning, laundry, etc.)
Figure 8.1: Cooking food
• Home healthcare
• Control of wastewater
• Waste disposal at household level
• Care of domestic animals and pets
• Control of insects
For communities without access to safe sanitation and water supply it also means:
• Safe disposal of human feces
• Household water including safe storage, handling and point of use treatment
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What is Personal Hygiene?
Microbes are found in all areas of the skin and mucous membranes such as the mouth and nose.
Microbes found on the body surface may either be transient or resident flora.
Resident flora(normal flora) are those microbes that colonize or live on, and are thus normally found
on, the skin. They are not generally pathogenic (disease causing) except if transferred to other areas
of the body, for example, the urinary tract, or the skin through a cut or an abrasion.
Transient flora are those microbes that are picked up onto the skin (mainly the hands) by touching
surfaces, food, infected people and pets during our day-to-day activities. If the surface which is
touched is contaminated with germs, then these are likely to be transferred to the hands, etc.
Transient microbes do not usually colonize the skin surface, but can remain viable and infectious for
significant periods on the skin surface and can, if they gain entry to the body through the mouth,
through cuts and abrasions, through the membranes of the nose or eyes, cause infections.
Some of these microbes can produce an infection if transferred to other areas of the body, for
example, the urinary tract, or if they enter a cut or abrasion. This is known as “self-infection”.
Figure 8.2: Bathing
Regular bathing/showering, hand washing, and
good general personal hygiene can reduce the risks
of self-infection.
Cutting nails reduces the risk
Though we wash our hands well at all critical times,
the bacteria and dirt can get stored under the nails.
So when we bite our nails, the bacteria enter our
mouths and this leads to diarrheal diseases.
Nail cutting regularly with blade/scissors/nail cutter
reduces the risk of infection.
Figure 8.3: Nail Cutting
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Personal hygiene during menstruation
Managing menstruation is essentially dealing with menstrual flow while continuing regular
activities like going to school, working, etc. Menstruation as a regular process needs hygienic
management.
Products used during menstruation are:
• Clean cloth: These are cut to fit in the panty area by sewing several layers of cotton rags
on top of each other. These must be clean. They must be washed thoroughly and hung in a
sunny place to dry. They should not be shared with others.
• Pads or sanitary napkins: These are designed to fit the panty area close to the body. Sanitary
napkins manufactured by a number of companies are readily available in the market.
One needs to change sanitary napkins regularly during the period of menstruation, especially in
the first three days. This can help prevent infection. During the heaviest days of your period, one
may need to change them every 3–4 hours.
In cases where cloth napkins are used, they need to be washed properly and dried in the sun in
order to kill germs and bacteria that may be present. Always ensure that the cloth napkins are
clean before using. After use, separate the two parts, soak them in cool water and rinse. Then
wash as usual. Hang to dry. Iron if you want. Then they are ready to be used again.
Some relevant points to ensure that menstrual management is supported by schools are:
Presence of water in/near all toilets for personal hygiene.
• Reliability of supply of water.
• Equity in water collection.
• Incinerators/bins available in girls’ toilets for hygienic disposal of sanitary towels.
• Material to wrap soiled napkins available, for example, old newspapers.
• Safe, final disposal of contents (burning or deep burial).
• Sanitary pads available in school in case of emergencies.
• Many schools have rules on the proper use of toilets and monitor their utilization.
Never flush a sanitary napkin or cloth pad down the toilet as this may cause serious plumbing
problems.
Napkins should not be thrown into the toilets particularly the water closet. It is better to keep a
dust bin in the corner of the toilet. Wash the soiled napkins and squeeze dry. Keep old newspapers/
waste paper ready to wrap the washed napkin. Drop it in the bin. You can dispose the contents of
the bin after your cycle bleed is over or daily. This can be given away as waste to garbage collectors
in areas where they come to collect them. In case there is no disposal mechanism prevalent in your
locality, see about disposing it within your backyard itself either in a sanitary pit or by incineration.
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What is Food Hygiene?
Food hygiene helps prevent food-borne diseases at home. The WHO has devised a system of five
keys that can be used as a framework for food safety. The five key messages are:
1. Keep clean – prevent cross-contamination
Preventing cross-contamination means stopping germs from spreading from people, pets, pests,
and contaminated food or water, into food which is being prepared for eating.
Germs cannot move on their own, they are moved via hands, or hand and food contact surfaces (for
example, knives, chopping boards, cloths).
A person may be infected with food poisoning germs, but not show any symptoms of illness. This
means that everyone must practice good hygiene when preparing food.
2. Separate raw and cooked foods
Germs can also move by direct contact between contaminated food and “clean” food.
3. Cook food thoroughly
Food can be made safe to eat by heating at a particular temperature for a sufficient time.
4. Store food properly
Foods must be kept at the right temperature,
for example, hot foods kept hot, chilled
foods kept cold. If not, bacteria can grow in
food to an unsafe level.
If food has to be kept for more than two
hours it must be kept steaming hot or very
cool.
Keep food covered.
Figure 8.4: Covered Food
5. Use safe water and raw materials
Use safe water for preparing foods. If necessary, treat water to make it safe.
Food and vegetables to be eaten raw should be peeled, washed, and rinsed using clean water.
Some Key messages on safe cooking
• Washing hands with soap and drying them before cooking and at all critical times.
• Keeping the cooking space neat and clean.
• Using clean utensils and cloth while cooking as well as while serving food.
• Covered and proper disposal of waste food.
• Avoid coughing and sneezing while cooking.
• Keep hair tied neatly and covered while cooking.
It is important to understand that hygiene behavior as mentioned above should become a regular
practice in all homes. Mothers and children can learn more about it from the AWCs they visit. Another
source of learning is from theUrban Health and Family Welfare Centres or UHFWCs. The key messages
may also be shared with community members by urban ASHAs/ USHAs and the anganwadi workers.
A hand-out on hygiene is given in Annexure 7.
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SESSION 11: HAND WASHING
Session 11: Hand Washing
(60 minutes)
The objective of the session is to:
• Sensitize the trainees on the importance of handwashing as an important component of
hygiene.
• Educate on critical events during which handwashing is required and also the correct method
of handwashing.
Method of session moderation
The session would be moderated with help
of multiple methods, executed one after
another. Following are the methods, in
sequential order, that should be used to
facilitate the session:
• Game (Box 3.11)
• Large group discussion (Box 3.12)
• Hand washing demonstration
Figure 11.1 : Hand Washing
Box 3.11: Game on Understanding the Spread of Germs –Using Turmeric Powder
The objective of the game is to sensitize the trainees on the importance of hand washing as a
deterrent against the spread of infection and germs. In this game, turmeric powder would be used
as a medium to demonstrate the path that germs and contaminants follow in context of its spread
from one person to another. This will also be used to demonstrate the effectiveness of soap in
cleaning hands.
Steps for the game
Take a pack of turmeric powder and pour it in a vessel/container (if vessel is not available, large
sheet of paper can also be used, where turmeric powder can be poured over the paper).
Ask one of the trainees to dip his hand in the turmeric powder so that his/her palm is coated with it.
After that the trainee should be instructed to shake hands with other trainees. This will lead to
hands of other trainees getting smeared with turmeric too. The trainer should pause for a moment
here and highlight this event as a representation of how germs pass from one hand to other.
After the handshakes, all the trainees should be instructed to wash their hands with plain water.
By washing their hands with plain water, some of the turmeric stain will be washed out but the
colorwill not go completely.
Thereafter, the trainer should instruct everybody to wash their hands with soap. By washing their
hands with soap, the trainees will see that the color of the turmeric will completely come off. Here
the trainer should point toward the effectiveness of using a cleansing agent like soap to achieve a
complete handwash.
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Large Group Discussion – The experience of the turmeric powder game will lead to a discussion on the
trainees’ practical experience on the effectiveness of using soap for handwash. This will form the lead
for initiating a discussion on the importance of handwash and how it can impact upon the health of an
individual. Taking the discussion ahead the trainer should then delve into the critical moments when
handwashing must be practiced and how it should be performed.
Box 3.12: Why Hand Washing?
Figure 11.2: Need for Handwashing
Microbes can be transferred from unwashed
hands to other people, surfaces and food.
These include bacteria such as Salmonella,
Shigella, E. coli,and Staphylococcus aureus,
and viruses such as rotavirus and norovirus.
For example, a person with gastroenteritis is
likely to excrete the pathogen in their feces.
These germs are easily transferred to the
hands during visits to the toilet or by touching
feces. If the person does not wash their hands
effectively, the microbes can be transferred
to food during meal preparation. Ingestion
of these microbes by another person could
then cause illness. Microbes can also be
transferred directly from hand to mouth. This
is known as “fecal-oral transmission”.
The major contamination source may include any contact with human excreta, soiled nappies, raw
food, pets, and contaminated surfaces such as toilets, sneezing, coughing, and transfer of nasal
secretions to the hands.
Hand washing is one of the most important
ways of preventing the spread of infection.
Handwashing is the vaccination against
diarrheal diseases.
Handwashing is important after touching
fecesor before touching food.
Following are events where handwashing
must be followed as a thumbrule:
• After using the toilet or disposing feces
Figure 11.4: Disposing faeces
• After changing babies’ nappies and disposing their feces.
• Before preparing food.
• Before eating food or feeding children..
• Immediately after handling raw food (for example,chicken, raw meat, vegetables, grains etc.).
• After contact with contaminated surfaces (for example,rubbish bins, cleaning cloths).
• After handling pets and domestic animals.
• After contact with blood or body fluids (for example, wounds, vomit, etc.).
• Before and after dressing wounds or giving care to a sick person.
• After wiping or blowing your nose.
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Demonstration – This method would entail the demonstration of the correct method of performing
hand wash by the trainer.
Figure 11.5 Steps for Hand Washing
Steps for correct handwash procedure:
• Always wash hands under running water.
• Apply soap.
• Rub hands together for 15 to 30 seconds, paying particular attention to the fingertips, thumbs,
and between the fingers.
• Rinse well under running water and dry thoroughly using a clean towel.
• Hand washing at critical times is an important message for mothers and children visiting AWCs
and UHFWCs, and children going to school.
Here the trainer can also use the handwashing chart. A hand-out on hand washing is given in
Annexure 8.
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SESSION 12: DIARRHEA PREVENTION AND MANAGEMENT
Session 12: DiarrheaPrevention and Management
(60 minutes)
Among these waterborne diseases, diarrheais the only one that can be managed at home while the
rest require consulting medical professionals. Also, severe diarrheamay still require medical help.
Given the large incidence of diarrheal episodes and its possible management at home, the current
section deals with details of diarrheaprevention and management related topics.
The objective of the session is:
• To educate participants on diarrhea, its symptoms, and its impact on health.
• To inform participants on diarrheaprevention measures.
• To inform participants on diarrheamanagement.
Waterborne Diseases
Waterborne diseases are caused by pathogenic microorganisms that are most commonly transmitted
in contaminated fresh water. Infection commonly results during bathing, washing, drinking, while
preparing food or the consumption of food thus infected. Various forms of waterborne diarrheal
disease probably are the most prominent examples. Some other important waterborne diseases
are presented in Table 3.6.
Figure 12.1: Child suffering from water borne disease
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Table3.6: Waterborne Diseases
Category of Disease
Fecal-Oral Diseases
Intestinal Worms
Diseases
Diarrhea
Cholera
Giardia
Amoebic dysentery
Typhoid
Hepatitis
Polio
Hookworm
Roundworm
Brief description of category
Generally
contracted
through the ingestion of
fecalcontaminated matter.
This can also be waterborne.
Transmission can occur through
contaminated hands, food,
flies, or contaminated water.
Piped water supply can be
contaminated when they run
parallel with sewerage,if the
pipelines are cracked.
Parasitic worms whose eggs
are passed in feces and who
need a period of time in moist
soil before they can become a
threat to human health. They
enter humans through food or
by penetrating the skin (feet).
In areas where open defecation
is high and close to human
settlements worm infestations
are also high.
In India, despite the reported growth in terms of coverage of the population with improved water
and sanitation facilities, approximately 12 million cases of diarrhea, about a million typhoid cases,
and 0.15 million viral hepatitis cases are reported annually. The rest are in much smaller in numbers.
Method for session moderation
This session targets the supply of specific inputs on diarrheaprevention and management.
Therefore,a participatory lecture or large group discussion would be the best method to conduct
the session. The discussion should focus on the following aspects:
Diarrheaas a health issue arising out of the water and sanitation problem.
Method for session moderation
This session targets the supply of specific inputs on diarrheaprevention and management. Therefore,a
participatory lecture or large group discussion would be the best method to conduct the session. The
discussion should focus on the following aspects:
• Diarrheaas a health issue arising out of the water and sanitation problem.
• Prevention measures.
• Management of diarrhea.
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The trainer should initiate the discussion by asking cue questions like:
• What is diarrhea?
• What causes diarrhea?
Based on the reaction of the trainees on the cue questions, the trainer should take the discussion
forward and cover topics for the session’s discussion. The contents for discussion on the subject should
focus on the following:
What is Diarrhea?
Diarrheais the condition of having three or more loose or liquid bowel movements in a day.
Children are more susceptible to the complications of diarrhea because a smaller amount of fluid
loss leads to dehydration, compared to adults.
I. WHY IS Diarrhea ANGEROUS?
It results in dehydration and ultimately death.
Thenet result is malnutrition.
Diarrheaoccurs so often that people do not take it seriously. But diarrheacan be dangerous.
II. WHAT IS DEHYDRATION?
Dehydration is the loss of water from the body.
When a child has diarrhea, she loses a lot of water with every loose motion.
If this water is not replaced fast enough, he/she will become weaker and weaker.
Most children die from diarrheabecause they do not have enough water left in their bodies.
An excessive loss of body fluids, which includes loss of vital salts like sodium chloride potassium
and bicarbonates.
Causes of diarrhea:
Most diarrheais due to fecalcontamination.
The following are the causes of diarrhea:
• Using dirty/unsterilized feeding bottles which carry germs.
• Consumption of unsafe water.
• Eating unhygienic foods like eating spoilt foods or food that is infested with flies.
Defecating in the open, for example, in the fields where the fecesmay come in contact with
humans through vegetables;defecating near houses, where flies may carry the germs and spread
them by sitting in the foods;defecating near water sources contaminating the water source;no
handwashing causing the fecesto enter into our system directly.
Dirty hands and nails.
The F-Diagram can explain this transmission route.
Allergies, indigestion, and chemical aggravation can also cause diarrhea.
Transmission of diarrheahappens through contact with the virus/bacteria mentioned above.
Measures to reduce transmission emphasize the following practices:
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• Safe and improved water supply.
• Safe excreta disposal.
• Improved domestic and food hygiene.
• Simple hygienic measures like hand
washing with soap
• Before preparing food
• Before eating
• Before feeding a child after defecation
• After cleaning a child who has
defecated
• After disposing of a child`s stool
• All families should have a clean and
functioning latrine.
Figure 12.2: Open defecation
Anganwadi workers and urban ASHAs/USHAs can play an important role inpreventing diarrheaby
conveying these messagesthus reducing the transmission of the virus/bacteria, detailed ahead.
Management of Diarrhea
Diarrheamanagement basically consists of the following steps:
Step 1: Understanding the symptoms of dehydration:
• Dry Mouth and Thirst(This is the first and most important sign of dehydration.).
• Sunken Eyes.
• Dark and little urine.
• Pinch of skin goes back slowly.
• Slow and weak pulse.
• Sunken fontanel (for infant).
• Drowsiness.
Step 2: Seeking medical help
One should also see a doctor if he/she experiences or witnesses any of the following:
• Excessive thirst, very dry mouth, very little or no urination.
• Severe abdominal pain .
• Severe rectal pain.
• Blood and mucus in the stools;black stools .
• Body temperature of over 39 OC (102 OF).
In context of children, if they have the following symptoms, a doctor should be consulted
immediately:
• The child is three months to a year old and the diarrheahas lasted over two days.
• The child is over a year old and the diarrheahas lasted more than five days.
Step 3: Treatment/management at home
Fluid replenishment
Oral Rehydration Solution (ORS) can be used to prevent dehydration.
Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken
soups with salt can be given.
Clean plain water can also be one of several fluids given.
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Key steps in preparation of ORS:
• Wash hands with a clean soap bar.
• 1000 ml or five glasses of drinking
water should be taken in a clean
container.
• Empty the content of the ORS packet
into it, stir and start feeding the
patient. Please read and note the
instructions on the packet before
mixing into the water because it will
have clear instructions on whether
the quantity is for five glasses
(1 litre of water)/200 ml (one glass).
• Fluids prepared at home may also be
given to the patient along with the
ORS when the person has diarrhea.
Figure 12.3: How to prepare ORS
• In case of children suffering from diarrhea, they may be given half to one glass of ORS solution
after every bout of diarrhea.
• Adults may be given one to two glasses of ORS after every bout of diarrhea.
• Where an ORS packet is not available, one can make home available solutions (HAS) at home:
• Take six level teaspoons of sugar and half level teaspoon of salt and dissolve in 1 litre of clean water.
• Be very careful to mix the correct amounts. Too much sugar can worsen the diarrhea. Too
much salt can be extremely harmful to the child.
• Diluting the mixture too much (with more than 1 litre of clean water) is not harmful.
Homemade Fluids
The important message is: drink lots of water or consume food high in fluid content. The fluids,
which are part of our normal diet, can be identified and used during the diarrheal spell. Some
homemade fluids include:
• Rice gruel
• Dhal water
• Tender coconut
• Weak black tea
• Fruit juices (especially citrus)
• Ragi malt
For infants, breast feeding must be continued.
Food
If the affected person is able to eat, avoid greasy or fatty foods.
Adults, infants, toddlers, and children should be encouraged to follow simple oil free/less oil and
less spice diet that is not heavy on the stomach.
Activity
Individuals should continue their usual activities if they are mildly ill with diarrhea; however,
strenuous exercise should be avoided until they feel better because exercise increases the risk of
dehydration.
Pregnant women with diarrhea should make sure to rehydrate to avoid dehydration, and should
consult their physician.
A hand-out on diarrhea management is given in Annexure 9.
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SESSION 13: TRAINING FACILITATION METHODS and TECHNIQUES
Session 13: Training facilitation methods and techniques
(60 minutes)
The objectives of the session are to:
• Acquaint the participants on basic training facilitation methods.
• Inform the participants on the basic issues that need to be taken care of while conducting a
training or communicating with participants/community.
Method for session moderationFigure 13.1 : Training
The method for session moderation would be a
large group discussion. The trainer should apply
the following methods by supplying specific
inputs:
• Training and communicating skills.
• Lecture/large group discussion method.
• Case study method.
• FGD method.
Study material for preparation of notes on the above areas is available in a hand-out. In addition to all
of the above, the trainer should also update the participants on the dos and don’ts while facilitating
training. The inputs for the same are elaborated in a hand-out.
Training and Communicating Skills
Training and communication is an important and powerful medium for learning and capacity
building. The trainer or facilitator of training plays the most important role in facilitating the learning
process in training.
It has four major components:
• Subject
• Method
• Trainees
• Trainer
Among all the four components, it is the trainer who binds the rest of the components of the
training and has the sole responsibility of anchoring the learning process on the target subject using
specific methods. As a result,being a trainer calls for basic skill prerequisites. These are as follows:
Analytical and coordination skills
The trainer should have the capacity to analyze problems, situationsand information, and synthesize
all of these to draw a conclusive interpretation.
The trainer should be able to design the learning process, that is,structure the training process (in
the form of methods) and execute the same.
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The trainer should be able to analyze the learning needs of the trainees and logically pursue the
learning process.
Communication
The trainer should have a strong command over his/
her language and should be able express himself/
herself lucidly.
She/he should have the ability to use language
in simple form, which is easily understood by the
target audience.
The trainer should be an active listener.
The trainer should be able to prepare learning aids
(PPTs, case studies, handouts, etc.).
The trainer should be able to prepare documentsand
reports.
Figure 13.2: participative training
Leadership
The trainer should be able to manage large groups and also coordinate groups of trainees.
He/she should have the skills to manage conflicts arising at both individual and group levels in the
process of learning.
He/she should have the ability to inspire the trainees.
Lecture/Large Group Discussion (LGD) Method
This training method entails a trainer to deliver a lecture (speech) to the trainees. Over the years this
method has been modified to some extent along the participatory principle by involving learners in
the lecture process. Therefore, sometimes it is also referred to as a large group discussion method.
The participation of the learners is ensured generally by asking leading questions of the topic of
lecture and seeking their response. The response from the learners forms the basis of trainer’s
lecture delivery.
Any new information or concept is introduced through a lecture. It can arouse interest in the learners
and set the stage for what is to follow next. A lecture can also be used to summarize the topic at the
end of the session. It allows the trainer to cover a great deal of the topic in a short period of time.
But at the same time, entailing the participation of the learners in this method is challenging.
A lecture can be supplemented with charts, PPTs, audio-visuals, etc. Reading materials can be used
before, as well as after a lecture. Therefore, a lecture can take a range of forms, depending on the
lecture as well as the learners and the subject.
When should a lecture be used?
A lecture is an appropriate training method in the following contexts:
• Presenting new information and concepts in an organized way.
• Identifying or clarifying problems or issues.
• Stimulating or inspiring the learners.
• Encouraging further study or inquiry.
• Tips for the trainer for an effective lecture
• The subject should be prepared ahead of the session.
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• It should be clearly linked to the learning objectives.
• The introduction to the lecture should be crisp and stimulating.
• The trainer should be prepared to inform the trainees how the lecture is linked to their learning
objectives.
• Use of different aids can be made (PPTs, white board, charts, etc.).
• Trainee’s participation should be ensured through involving them in the discussion.
• The language of the lecture should be simple and easy to understand.
Case Study Method
The case study method involves use of real life experiences of an individual, a group, an organization,
a slum, other than the learners themselves. This could either be through an oral process or written
documents. Depending upon the subject matter and learning objectives, case studies could either
be content based or process based or a combination of both.
Figure 13.3: Adult Learning
The objectives of using a case study as
a method for training facilitation are:
To supplement certain information as
well as theoretical concepts presented
to a group of learners. In this way, it
helps to elucidate various underlying
principles to further highlight and
clarify certain critical issues as well
as to present a living example of how
these concepts apply.
In the event of understanding the
dynamics of any particular situation,
it triggers a process of reflection and
application on the part of learners.
They can draw parallels with their own set of experiences or even see the main differences.
To discuss and further evaluate varying approaches used in similar or different contextual situations.
Essentially, what it demonstrates is that there are various ways of perceiving a problem and handling
it.
To sharpen the learner’s analytical and diagnostic skill.
To expose learner groups to situations and examples that would serve as learning models for them.
To create new knowledge through a process of collective reflection and analysis, new theoretical
constructs can emerge.
Steps
The case study method involved the following steps:
• Reading or hearing the case study
• Individual reflection
• Small group discussion/FGD (to explore the issue further)
• Extract insights
• Collective analysis
• Summarization
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Advantages
Case studies can contribute significantly to a process of:
• Option creating: Presenting a wide range of methods and approaches to a similar problem.
• Awareness raising: Understanding the underlying causes and factors that have either enhanced
or hampered a particular process.
• Further developing planning and analytical skills: Using other people’s experiences as valuable
insights and base for learning.
• Cognitive input: Contribute to new understandings and conceptual framework.
FGD method
The focus group discussion (FGD) or small group discussion is used when experiences of the trainees
needs to be stimulated for generating information, opinions,and ideas on a particular subject.
Group participation is the basis for the small group discussion method. All members in the group
can get an appropriate opportunity to share their experiences, opinions, and ideas. Such a method
stimulates thinking and actively involves all members of the group.
The small group discussion method can be most effectively used in a group of five to ten members.
In a group larger than that, promoting effective participation becomes problematic. Following are
some of the main rationale for a small group discussion:
• Clarification: Mutual discussion helps clarify the issues and different positions to it.
• Opinion building: Learners can crystallize their opinion in a collective context.
• Expression: Small group discussion can encourage expression of learner’s experiences and
opinions.
• Involvement: It can be used to initiate and sustain learner’s involvement.
• Internalization: It can facilitate internalization of crucial ideas among learners.
Steps for conducting small group discussion are:
• The trainees should be divided into small groups consisting of five to ten people. The group can
be formed either through random selection of members or purposive selection, depending on
the focus of discussion agenda.
• The topic of discussion needs to be explained clearly to the groups formed.
• The trainers need to facilitate the group discussion and ensure that all members participate.
• All the groups need to arrive at some consensus point, which should be presented by a
member(s) nominated by the group.
The trainer should collate all the consensus points emerged from group discussion with the larger
objectives of the training and provide inputs on the topics.
The trainer should wrap the session by forming five groups of trainees, who would participate in a
mock exercise for practicing the methods of session conduction in the next session.
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Session 14: Role of Anganwadi, Urban ASHA/ USHA Workers
(60 minutes)
The objective of the session is to:
Discuss and bring clarity to the role of the anganwadi worker and urban ASHAs/ USHAs in promoting
WASH.
The method for session moderation would be a large group discussion. The trainer should use the
following methods of training by supplying specific inputs:
• Potential role of anganwadi worker in WASH.
• Potential role of urban ASHAs/USHAsin WASH.
The trainer should initiate the discussion by asking cue questions like:
• What is the potential role of the anaganwadi worker in promoting WASH?
• What is the role of urban ASHAs/ USHAs in promoting WASH?
Based on the reaction of the trainees on the cue questions, the trainer should take the discussion
forward and cover topics for the session’s discussion.
Integrated Child Development Services (ICDS) Centre
For a mother and child, the safe practice of handling water, sanitation, and hygiene is key to
their health and well-being. It is also important for reducing morbidity and mortality. The ICDS
program primarily focuses on catering to the needs of children under the age of six years through
supplementary nutrition, healthcare, and preschool education. It also covers adolescent girls,
pregnant women, and nursing mothers.
The Government of India started the ICDS in 1975 with the following objectives in mind:
• To improve nutritional and health status of children below six years age.
• To lay down the foundation for proper psychological, physical, and social development of the
child.
• To reduce the incidence of mortality, morbidity, malnutrition, and school dropouts.
• To achieve effective co-ordination of policy and implementation among various departments to
promote child development.
To enhance the capability of a mother to look after the normal health, nutritional, and developmental
needs of her child through proper community education.
Water Sanitation Hygiene and ICDS
Children and mothers come in close contact with anganwadi workers. WASH is of greater importance
to both these target groups. An ICDS center can be an information center for mothers and children
to adopt hygiene practices.
A center with clean water, sanitation, and hygiene facilities entails:
Access to safe water (preferably a safe water supply connection – piped water, Hand Pump).
Safe water storage being used for cooking and drinking.
Access to a child friendly latrine and latrine for staff.
Handwashing station.
Joyful learning on WASH.
Hygienic kitchen with good food hygiene practices
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Provision of basic utensils, etc., for keeping food covered and safe .
Ensuring cleanliness of vessels, plates, and glasses used for providing food and drinking water to the
target group of AWCs.
Keeping the surroundings of the AWC clean, free of vectors and parasites.
IEC which includes display of communication materials like posters, pamphlets.
Information booklet on various development schemes including health and WASH
(See Annexure 10).
Key WASH messages for ICDS are:
• Washing hands with soap at critical times
can reduce the risk of diarrheal diseases by
42–47 percent.
• Use safe water:
• Use a safe water source – pump, sanitary
well.
• Safe water handling – collection, storage
and consumption:
• Water source may be a safe one but it
gets contaminated due to unhygienic
water handling practices and unhygienic
surroundings.
Adoption of low cost techniques to purify water:
• Water gets contaminated during
transportation, storage, and at point of use.
Figure 14.1: Safe practices in AWCs
• Water gets contaminated more at point of use than at source.
• Use of a sanitary latrine.
Food hygiene:
• Keeping food covered and in an elevated place.
• Washing vegetables before cooking and fruits before eating.
• Diarrhea management:
• Safe treatment practices during episodes of diarrhea.
Urban Health and Family Welfare Centers and WASH
At the first level are the urban health posts, mostly with outpatient and referral services. The second
level consists of civil hospitals and maternity centers. Then come the area and district hospitals.
Lastly, at the fourth level, the tertiary hospitals.
Figure 14.2: Safe practice of serving Mid Day Meals
The Urban Family Welfare Centers and
Urban Health Posts provide comprehensive
integrated services of RCH and outreach
services in urban areas. The Urban Family
Welfare Centers and Urban Health Posts are
envisaged to function in close coordination
with the anganwadi centerin their respective
areas. Urban health and family welfare centres
offer MCH, child health and other services.
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Convergence Role
Health and ICDS have a role complementing each other. The following table lists the same:
Table (7 ) : Converging roles of Health and ICDS
Services
Target Group
Service Provided by Proposed Services Proposed WASH
for MAS and USHA component that
may be covered
Supplementary Children below 6
Anganwadi Worker + MAS/ USHA
Diarrhea
Nutrition
years: Pregnant & and Anganwadi
management
Lactating Mother Helper
Food Hygiene
(P&LM)
Immunization* Children below 6 ANM/MO
+ MAS/ USHA H a n d w a s h i n g
years: Pregnant &
Facilitate in listing Cleanliness
Lactating Mother
(P&LM)
Health Check-up* Children below 6 ANM/MO/AWW + MAS/ USHA
Convergence for
years: Pregnant &
Lactating Mother
(P&LM)
JSY scheme
Referral Services Children below 6 AWW/ANM/MO + MAS/ USHA
years: Pregnant &
Lactating Mother
(P&LM)
Pre-School
Children 3-6 years AWW
+ MAS/ USHA
School Hygiene
Education
promotion
Nutrition
& Women (15-45 years) AWW/ANM/MO + MAS/ USHA
Modules
on
Health Education
safe water, safe
sanitation to aid
reduction of WASH
related illness
Identification of
AWW/ANM
+ MAS/ USHA
Target Groups*
(Register updation
at slum level)
Health
and
AWW/ANM
+ MAS/ USHA
Key messages on
Nutrition Day
WASH
Accreditation standards for Primary Urban Health Centre set by National Accreditation Board for
Hospitals and Health Care Providers has detailed out the infrastructure and others details regard to
water sanitation which are given below:
• Availability of running tap water for hand washing of staff to be maintained 24 hours a day
• Sanitation of the toilets and hygiene of the staff to be maintained
• The hospital environment to be kept clean from litters, pest and stray animals.
• The facility shall have Reverse Osmosis (RO) Plant.
• The center shall promote sanitation hygiene and availability of potable water in the community
by involving the RWAs, Self Help Groups and NGOs.
• The center shall distribute chlorine tablets to the community and educate them about their
usage.
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• The perils of open defecation to be informed to the community living in JJ clusters and slums.
• Creation of soak pit and trench lavatories to be carried out by involving the local self help groups
and NGOs in JJ clusters and slums.
• Health education and maintenance of hygiene to be done by adopting the principles of school
health and involving public opinion makers.
• A plan to combat disasters, epidemics in the community shall be ready in the facility,
communicated to all concerned and rehearsed at least twice a year.
In the waiting area:
• The walls shall carry posters imparting health education.
• Booklets / leaflets may be provided in
the waiting area for the same purpose.
• Toilets with adequate water supply
separate for males and females shall be
available, preferably with Western and
Indian WC sheets.
• Drinking water shall be available in the
patient’s waiting area.
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SESSION 15: FORWARD ACTION PLANNING
Session 15: Forward Action Planning
(30 minutes)
In this session, the trainer tries to develop an action plan, which would entail the following:
• Identifying potential community groups and locations to impart training to the community.
• Identifying potential time, place, and number of trainings that can be conducted at the community
level.
• Deciding the responsibilities of the trainees (community group, location and person specific if
required) in conducting the trainings.
• Deciding the modules and sessions for training as per need from the sections in the manual.
The action plan would be developed through the large group discussion method.
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SESSION 16: ADMINISTERING KAP QUESTIONNAIRE AND FEEDBACK
Session 16: Administration of the KAP Questionnaire on WASH (Post training) and Feedback
(15 minutes)
In this session, the same KAP questionnaire that was administered in session 3 would be administered
again to the trainees. The objective is to assess the improvement that has taken place due to the
training. The exercise should be completed in 10 minutes.
Another feedback sheet on the training would also be administered to the trainees to capture their
satisfaction level with the training.
The KAP Questionnaire is placed as Annexure 2. The Training Feedback Questionnaire is placed as
Annexure 11.
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SESSION 17: VALEDICTORY
Session 17: Valedictory
(10 minutes)
The Valedictory session should include the following:
• Reiteration of the objective of the training and its importance.
• Discussion among participants and trainers on the current training program.
• Participants’ expectations.
• Conveying gratitude to participants, trainers, organizers, funders, and support staff.
• Closing with a motivational message.
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CHAPTER 4
GUIDANCE TO FACILITATORS
This note is for the facilitator to assist her/him in carrying out the training effectively. By taking note of
the discussions given below a facilitator or a trainer can impart training with impact.
4.1 DOs AND DON’Ts
There are certain basic aspects which need to be kept in mind while facilitating a training program.
These aspects have been presented below in the form of Dos and Don’ts for the training program.
Dos
• The training plan and design should be ready at least one week in advance.
• The participants should be informed at least three days in advance about the training date and
provided information on logistics.
• Training materials preparation and all logistic arrangement should be completed before the
training dates.
• The trainer should build a profile of all the expected participants and assess individual training
needs.
• The seating arrangement in the training hall should be appropriate and should in no way hinder
the learning processes.
• Sessions must be conducted in a timely fashion and all timelines strictly followed.
• A process of appreciative enquiry is facilitated in all the sessions of the training.
• Ground rules for conducting the training, with participation of the trainees, should be fixed on the
first day. A group of trainees should be assigned the responsibility to monitor that the rules are
adhered to and closely followed.
• Special care should be taken to ensure that food and other amenities are of good quality and
properly implemented.
Don’ts
• Any point or curiosity raised by trainees should be respected and responded to. Any opinion
expressed in the context of the subject should not be discarded as irrelevant, even when not
related directly to the topic.
• Individuals should not be exposed to scrutiny by others on sensitive or personal subjects.
• The trainer should not allow conflict to emerge as a result of different opinions in the training
groups.
• Deviation in the training session’s objective should not be allowed and must be contained through
intervention by the trainer.
• The trainer should enforce his/her views as the dominant perspective on any topic and subject.
The trainer’s views should be supported by facts and figures.
4.2 POTENTIAL TRAINER OR FACILITATOR PROFILE
It is important for the trainer to have certain skills and etiquette for training and facilitation. This
section focuses on these soft skills of the trainer/facilitator:
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A deep awareness of the subject and the audience/ target group is desirable.
It is important that the trainer have a good understanding of WASH in the urban context and urban
poverty.
She/he must understand the audience or the urban poor who are the final target audience.
The trainer/facilitator must be familiar with the different games and exercises that need to be
administered for each session.
The entire training module consists of different exercises and games. The trainer should be familiar
with these methods and should be aware of what it can use for training key urban functionaries or
what is suitable for the community. She/he should also think of innovative ways of making changes in
the games, without changing the underlying key messages, based on local context.
The trainer/facilitator must be aware of learning methods for adults.
Children learn based on their belief in what they are being taught. Adults, on the other hand, learn
when they feel there is a need to learn. Adults like to reconnect what is being taught to them with past
and present experiences. Further, they learn best when the environment for learning is comfortable
and enabling rather than conflicting and threatening.
The trainer/facilitator must be aware of the recall capacities of adults.
Human beings have both long-term and short-term memories. The long-term memory is information
stored over a period of time while short-term memory is the ability to remember and process
information at the same time. To help catalyze and enable the human brain to convert the learning
and knowledge from the training program, which requires remembering and processing information
at the same time, it is important for the trainer to undertake recalls at frequent intervals and recaps at
the end of the day and at the beginning of the next session the following day.
Recall should be connected to key messages of the modules/sessions so that participants connect,
capture, and remember.
The trainer/facilitatorshould be able to make the adult participant think and activate his brain.
To convert the information, learning, and knowledge shared during the training program into a long-
term memory for the participant, it is essential that the mind/brain of the participant be activated and
kept alert and thinking.
To achieve this, games and exercises have been introduced.
The trainer can also modulate her/his voice to capture participants’ attention.
The trainer can ask questions and make the session interactive.
Training delivery may include the following:
• Never be late for training sessions.
• Keep the training session simple and uncomplicated.
• All supportive materials kept ready prior to the training.
• Careful and Clear Communication.
• Maintaining eye contact with participants.
• Play interesting games, share interesting examples, use ice-breaking sessions for breaking the
monotony of long sessions and sessions post lunch.
• Do not out documents; may only read out quotes from texts.
• Be confident and deploy open body language. The trainer/facilitator may exaggerate body
movements as a performer.
• May pause while talking.
• Use humor and display enthusiasm.
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ANNEXURE 1
VARIOUS POLICIES, SCHEMES AND PROGRAMS ON URBAN WATER
SUPPLY AND SANITATION
Over the last sixdecades since independence the country has recorded significant economic growth
but access to and availability of safe water and sanitation remainsa cause of worry and this is reflected
in the various five year plan documents. The importance is recognized in the planning process and
endorsed/ re-endorsed in the various sectoral policies and programs.
Table A1: WASH in Sectoral& Sub-sectoral Policies
S. No. Reference Document
Reference Points on WASH
1
National Water Policy 2002
Adequate safe drinking water facilities should be provided
to the entire population, in both urban and rural areas.
Ministry of Water Resources,
Government of India
Irrigation and multipurpose projects should invariably
include a drinking water component, wherever there is
no alternative source of drinking water.
Drinking water needs of human beings and animals
should be the first charge on any available water.
2
Draft National Water Policy, 2012 Recognizes the right to WATSAN.
Ministry of Water Resources, The central, state and local bodies must ensure a minimum
Government of India
quantity of portable water, available within easy reach
of the household, for essential health and hygiene to all
citizens.
Urban domestic water supplies should preferably be from
surface water. Where alternative supplies are available,
a source with better reliability and quality needs to be
assigned to domestic water supply.
3
National Health Policy, 2002 The attainment of improved health levels would be
significantly dependent on population stabilization, as
Ministries of Health and Family also on complementary efforts from other areas of the
Welfare, Government of India social sectors--like improved drinking water supply, basic
sanitation, minimum nutrition, etc.—to ensure that the
exposure of the populace to health risks is minimized.
To reduce mortality by 50 percent on account of TB,
malaria and other vector and waterbornediseases by
2010 is one of the objective of the health policy.
4
Draft National Urban Health Aims to address the health concerns of the urban poor
Mission (2008–2012)
through facilitating equitable access to available health
facilities by rationalizing and strengthening the existing
Urban Health Division, Ministry capacity of health delivery for improving the health status
of Health and Family Welfare, of the urban poor.
Government of India
It focuses on establishing synergies with programs of
similar objectives like Jawaharlal Nehru Urban Renewal
Mission (JnNURM), Swarna Jayanti Swarozgar Yojana,
ICDS.
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S. No. Reference Document
Reference Points on WASH
5
National Nutrition Policy, 1993 Undernutrition in urban areas is a major concern. It says
the status of urban slum dwellers in India is almost as bad
Department of Women and as that of rural poor.
Child Development, Ministry of
Human Resource Development, The children of urban slums dwellers are nutritionally
Government of India
the most fragile. One of the causes may be poor sanitary
condition.
6
National Policy for the Special attention will be given to the needs of women
Empowerment of Women, 2001 in the provision of safe drinking water, sewage disposal,
Department of Women and toilet facilities and sanitation within accessible reach of
Child Development, Ministry of households, especially in rural areas and urban slums.
Human Resource Development, Women’s participation will be ensured in the planning,
Government of India
delivery, and maintenance of such services
7
National Policy for Urban Street Provision of civic facilities including provision of drinking
Vendors, 2009
water and public toilets at vending zones/vendors market.
Ministry of Housing and Urban
Poverty Alleviation, Government
of India
Table A2:Various Schemes and Programs on WATSAN
Sl. No. Name of the Schemes and Provisions
concern Ministry
1
Jawaharlal Nehru National Urban The Government of India’s JnNURM targets 63 key
Renewal Mission (JNNURM)
cities and urban areas, focusing on services to the poor
as one of its explicit missions. It includes two sub-
Ministry of Urban Development missions: the Urban Infrastructure and Governance
(UIG)and the Basic Services to Urban Poor (BSUP).
Besides, two other reform-driven schemes—Urban
Infrastructure Development Schemefor Small and
Medium Towns(UIDSSMT) and Integrated Housing and
Slum DevelopmentProgramme (IHSDP)—were included
under JnNURM.
The BSUP seeks to provide a garland of sevenentitlements/
services—security of tenure, affordable housing, water,
sanitation, health, education and social security—in
low income settlements in the 63 Mission Cities. The
IHSDP seeks to provide the aforementioned garland of
seven entitlements/services in towns/cities other than
mission cities.
2
Integrated Low Cost Sanitation The scheme is specifically designed to cover the
(ILCS)
economically weaker section of society. Itconstructs
or converts low cost sanitation units through sanitary
Ministry of Housing & Urban two pit pour flush latrineswith superstructures and
Poverty Alleviation
appropriate variations to suit local conditions. For
those who practiceopen defecation, new toilets are
built under the scheme. The central government shares
75percent of the cost while the state government
contributes 15 percent. Beneficiaries contributethe
remaining 10 percent.
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Sl. No. Name of the Schemes and Provisions
concern Ministry
3
Rajiv AwasYojana (RAY)
The scheme is being implemented from 2009 to 2016.
It aims to provide central government support to states
Ministry of Housing & Urban that attempt to assign property rights to slum dwellers.
Poverty Alleviation
RAY is the government’s key program to achieve a
“slum free India”. The scheme advocates an integrated
approach to slum development by giving legal tenure
to dwellers and building decent housing, and providing
basic civic and social amenities. Further, the benefits of
health, education, social security, construction workers’
welfare and livelihood, and public transport linkages for
holistic slum redevelopment are to be provided through
convergence of schemes available under the respective
sectors. All ULBs are entitled to access funds under the
scheme.
Provision of WATSAN in various policies and sectoral initiatives clearly reflects the importance
of WASH to improve the health and reducing gender and social disparity. This linkage stems from
the understanding that the Government of India, on the launch of the National Urban Health
Mission(NUHM), is envisaging convergence with other urban programs that include the JnNURM) and
the ICDS among others. At the same time, along with the Public Health and Engineering Department
(PHED)—primarily responsible for water supply and sanitation services—there is a need for closely
working with the Ministries of Housing and Urban Development, Urban Employment and Poverty
Alleviation, Health and Family Welfare, and Women and Child Development to address the health
needs and reduce the health risks of the poor in urban areas.
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ANNEXURE 2
KNOWLEDGE, ATTITUDE AND PRACTICE (KAP QUESTIONNAIRE)
FOR PRE TRAINING AND POST TRAINING IMPROVEMENT OF
UNDERSTANDING AND UPTAKE ASSESSMENT
WASH
KAP Questionnaire
I. Respondent’s information
Name of the participant
Designation
Organization/agency Name
Block
District
State
II. WASH – General understanding
2.1 Are you aware of the terminology/acronym “WASH” and what it stands for?
Yes
No
2.2 Do you have knowledge of the Fecal chart (F-chart)?
Yes
No
III. Safe Drinking Water
3.1 Identify below safe/clean sources of drinking water. Please mark your choices with (√) mark.
Piped water
Open well
Rain water collection
Tubewell
Ponds/water bodies with unrestricted access (human, animals, etc.)
Covered well
3.2 Identify below the factors that can contaminate sources of drinking water. Please mark your choices
with (√) mark.
Crack or fissures in pipe supply line
Washing, cleaning, or bathing around water sources
Discharging used water in drainage line
Installing portable (tullu) pumps in water supply lines
Constructing toilet septic tanks within 50 meters vicinity of water sources
Open defecation
Sprinkling bleaching powder around standpipe/tube well
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3.3 Identify the diseases that are caused due to contaminated water. Please mark your choices with
(√) mark.
Malaria
AIDS
Diabetes
Diarrhea
Cholera
Typhoid
TB
Dengue
Viral Hepatitis
IV. Safe Sanitation
4.1 Please choose the correct option(s).
Sanitation is management of_________
Human excreta
Solid waste
Drainage
None
4.2 Which do you think is safe sanitation practices?
Practices
Safe
Open defecation
Using flush latrine
Flushing toilet before & after use
Washing hand with plain water after
defecation
Washing hand with water & soap after
defecation
Discharging toilet effluent in open area
Unsafe
V. Hand washing
5.1 Hand washing with cleansing agent leads to __________ (Please choose the correct option(s)
Waste of water & money
Hands becoming free of germs
Restricts transmission of contamination/infection
5.2 Indicate the necessary item(s) required for performing correct hand wash
Water
Ash
Soap
Towel
Soil
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VI. Diarrhea
6.1 Diarrheais a condition where a person suffers from____ (Please choose the correct option(s))
Constipation
Loose motion (more than three times in a day)
Headache
Vomiting
6.2 Precautions that should be taken in diarrhea are: (choose the correct option(s))
Taking ORS
Consuming plenty of water
Eating a light diet
Consuming protein rich diet
No precaution is required
VII. Training Facilitation
7.1 Have you facilitated training before?
Yes
No
7.2 Are you aware of different of session facilitation methods (lecture, FGD, role play, etc.)?
Yes
No
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ANNEXURE 3
SAFE DRINKING WATER
SAFE DRINKING WATER IS IMPORTANT FOR GOOD HEALTH AND WELL-BEING
It is important to keep drinking water safe because:
• Water is essential for our health and we drink it to keep our body hydrated and for the proper
functioning of our organs.
• It is important to keep drinking water always clean because dirty water can carry germs which
cause infection and diseases.
• Some of the diseases that dirty drinking water can cause are diarrhea, jaundice, dengue, malaria,
polio, and skin infections such as scabies, etc.
Water meant for drinking can be made safe for consumption by the methods mentioned below:
• SODIS method
• Adding chlorine tablets
• Adding bleaching powder
• Boiling water
• Filtering water
Some steps we can take to keep drinking water safe and clean:
• In case we bring water from tankers, we must use clean pipes to limit any contamination at the
source of collection.
• While carrying water to our homes, we must ensure the vessel is covered so that no germs or dirt
can contaminate it.
• After administering one of the method’s to keep water clean and make it fit for drinking we must
ensure the following:
• The vessel with water kept for drinking is always covered.
• Use a ladle for taking out water and pouring it into a glass for drinking.
• Never dip a glass into the vessel.
• Never dip hands into the vessel while taking out water.
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ANNEXURE 4
CHLORINATION IN DRINKING WATER
Chlorine is a widely used disinfectant for deactivation of pathogenic microorganisms. It is popularly
used for disinfection of water because of its wide availability and cost-effectiveness.
For chlorine to be most effective it needs to come in direct contact with water having microorganisms
with minimum residual chlorine being 0.2mg/1 mg. Since it takes time to kill microorganisms it should
be left in contact with the water to be treated for 20–30 minutes. Contact time must also be increased
if the water is cold. One must test the pH value of water before chlorinating because if the water is
alkaline, it will take more time to disinfect. At normal pH values, 0.3–0.4 mg/litre residual chlorine is
desirable, at higher pH of 8–9, at least 0.4 mg/litre.
When chlorine is applied to water prior to any treatment, the process is called prechlorinationg. On the
other hand, post Chlorination involves application of chlorine to water prior to it entering a distribution
system. Yet another method is rechlorination, wherein service reservoirs, booster pumping stations,
and main service points in distribution zones are reintroduced to chlorination1.
The method of chlorination is different for households and for water supplies. The following section
describes these:
In case of chlorination for water supply:
As per WHO guidelines on drinking water for normal domestic use, residual chlorine levels at the point
where the consumer collects water should be between 0.2 and 0.5 mg/l; continuous chlorination is
taken up in piped water supply.
In case of other water supply, chlorination is taken up after repair and maintenance.
It is important to check that the chlorination process is working right after chlorinating the water.
One must check if the chlorination is within acceptable levels at the outlet of the consumer nearest
to the point of chlorination. It also must be checked at those points which are furthest and where
residual chlorine is expected to be low.
One should be cautious while handling chlorine as it is poisonous in any (gas, liquid, or solid).
You may be exposed to objectionable smelling and tasting water if the chlorine content is higher than
the recommended quantity.
A. Procedure for chlorinating at household level2:
• Chlorination at the household level can be either through the usage of chlorine tablets, bleaching
powder or sodium hypochlorite solution.
• Chlorine tablets should be used as stated in the manufacturer instructions. At doses of a few
mg/l and contact time of about 30 minutes, free chlorine inactivates more than 99.99 percent of
enteric pathogens. For instance, 0.5 gramweight of chlorine tablet containing 25 mg of Nascent
chlorine can be used to disinfect 20 liters of water.
• In case of solid bleaching powder (CaOCl2 ) 3 to 5 mg of bleaching powder is necessary to
disinfect 1 liter of water.
1 “Technical Notes on Drinking-Water, Sanitation and Hygiene In Emergencies,” World Health Organization, 2011 (http://
www.who.int/water_sanitation_health/hygiene/envsan/technotes/en/).
2 “Manual on Water Supply and Treatment,” CPHEEO, 1999 (http://www.indiawaterportal.org/node/12574).
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• It takes a minimum of half an hour for disinfection. Sixty to 100 mg or one pinch will disinfect 20
liters of water.
• Bleaching powder deteriorates rapidly when exposed to air and it should therefore be properly
stored and carefully handled.
• The bulk of the powder may be stored in a central place where the container can be properly
sealed after taking out the quantity required for immediate use.
• In the case of sodium hypochlorite, two to three drops of sodium hypochlorite solution
(approximately 4 percent available chlorine) may be added in 10 liters of water.
The solution should be kept overnight and tested for residual chlorine availability by using a Residual
Chlorine (RC) kit. Minimum residual chlorine available should be around 0.2mg/1. If the RC content is
found high, then water can be exposed to sunlight for the chlorine to escape as trihalomethanes(THMs)
may cause cancer.
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ANNEXURE 5
SAFE SANITATION
ALWAYS USE CLEAN, CONCRETE TOILETS FOR GOOD HEALTH AND WELL-BEING
It is important not to defecate in the open because:
• When we defecate in the open the fecesis exposed to air and water which are the carriers of
germs, viruses, and bacteria that are not friendly to our body.
• The virus and bacteria enter our body when we eat food with unclean hands, cook food with
unclean hands, or drink water with unclean hands.
• Once these harmful viruses and bacteria enter our body they cause infections and diseases.
• When others are exposed to food cooked with unclean hands or infected drinking water they
also fall sick and the disease begins to spread.
What should we do to prevent diseases from spreading from feces?
• We should always use clean, concrete toilets.
• The toilet should always be kept clean before and after using it.
• Keeping the toilet clean and washing with water after use not only washes away germs, but also
greases the toilet, so that less water may be used by the next person.
• It is the responsibility of the community (each one of us) to keep the community toilet clean in
case we have community toilets in our locality.
• We must wash hands with soap after using the toilet.
• In case a child defecates in the open, cover the defecation with soil, carry it to a toilet, and flush
it down with water. Clean the area of defecation with water and disinfectant. Wash your hands
with soap.
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ANNEXURE 6
SNAKES & LADDERS GAME
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ANNEXURE 7
HYGIENE
Health and hygiene are both connected. Poor hygiene leads to poor health and diseases. By adopting
good practices at different points of time to preventgerms from infecting us, we can prevent diseases
and enjoy good health.
OUR BASIC REQUIREMENTS FOR GOOD HEALTH
SAFE WATER: Basic requirement of every individual is water for safe drinking and for
performing hygienic practices.
SAFE SANITATION: Facilities/processes for safe disposal of human waste.
GOOD HYGIENE PRACTICES: Practices and behaviors for preservation of health.
To prevent the disease burden we must do the following:
• Food should always be covered.
• Drinking water should always be safely stored and handled from the source of collection to the
pointofuse.
• Wash vegetables.
• We must wash our hands with soap before cooking, while handling food, after using a toilet,
after cleaning a baby’s bottom, before and after cleaning the house, after returning from
outside, etc.
• We must keep our home and surroundings clean and use covered garbage disposal bins for the
collection of garbage.
• We must take precautions for our health by adopting good hygiene practices. We must always
keep our body clean and neat, our nails should be trimmed to avoid passing germs, and our
hair well brushed, etc.
• We must not allow waste water to flow in the open as it attracts many vectors which carry
diseases and germs.
• In case we do not have community toilets, shared toilets or personal toilets, feces should be
covered with soil to prevent exposure to air and water thus preventing the spread of harmful
disease causing bacteria or viruses.
• Feces should be buried far from habitation so that people or animals and vectors are not
exposed to it.
• Even domestic animals and pets should be taken care of such that any infection from them does
not spread to us or to others.
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ANNEXURE 8
HAND WASHING
Hands, if not washed properly, can still carry germs in the grooves of the palms and under the nails.
Therefore, we must practice the key steps:
• Wet your hands with water.
• Lather your hands with soap properly.
• Rub the soap lather on both sides of the hands properly.
• Rub the soap lather between your fingers.
• Rub your palms again.
• Soap and lather your nails.
• Soap and lather between the thumb and fingers.
• Rub fingers against the centre of each palm.
• Wash hands properly with running water.
• Raise hands to let the water drain off.
• Dry hands with a clean piece of cloth or towel.
The chart for hand washing may be demonstrated to understand the right way of doing it.
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ANNEXURE 9
DIARRHEA MANAGEMENT
Diarrheais the condition of having three or more loose or liquid bowel movements in a day. Children
are more susceptible to the complications of diarrhea because a smaller amount of fluid loss leads to
dehydration, as tocompared to adults.
Diarrheacan be caused by either virus or bacteria.
To prevent diarrheafrom occurring,the following are the basic measures that need to be undertaken:
• Provision of safe sanitation infrastructure.
• Safe drinking water, which comprises of source protection and water treatment before
consumption.
• Hygiene practices.
Management of Diarrhea
We must understand the symptoms of diarrhea: Passing of water stool more than three times a day,
along with dehydration.
We must seek medical help: When the following is experienced: excessive thirst, very dry mouth,
very little or no urination; severe abdominal pain; severe rectal pain; blood in the stools, the stools
are black; body temperature is over 39degress centigrade(102 degress Fahrenheit). If the child is aged
three months to one year and the diarrheahas lasted over two days; if the child is over one year of age
and the diarrheahas lasted more than five days. Pregnant women with diarrheashould make sure to
rehydrate to avoid dehydration, and should consult their physician. Individuals should continue their
usual activities if they are mildly ill with diarrhea; however, strenuous exercise should be avoided until
they feel better because exercise increases the risk of dehydration.
We may treat or manage diarrheaat home in the following way:
• Fluid replenishment
• Oral Rehydration Solution (ORS) can be used to prevent dehydration.
• Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken
soups with salt can be given.
• Clean plain water can also be one of several fluids given.
Food
If the affected person is able to eat, avoid greasy or fatty foods.
Adults, infants, toddlers, and children should be encouraged to follow a simple oil free/less oil and less
spice diet that is not heavy on the stomach.
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ANNEXURE 10
TRAINING FEEDBACK QUESTIONNAIRE
WASH training assessment format
I. General information
Name of the participant
Designation
Organization/Agency Name
Block
District
State
II. Purpose of the training
2.1 Training objective were clear: Please put (√) on your choice.
Training objectives were achieved: Please put (√) on your choice
III. Learning needs
Please register your satisfaction level in context of the objectives and learning needs that the training
session mentioned below were able to achieve (mark your answer with √ symbol)
S. No Particulars
1
Session 2: Expectation mapping & objective articulation
2
Session 4: Introduction of WASH
3
Session 5: Safe drinking water
4
Session 6: Clean drinking water interventions
5
Session 7: Safe sanitation
6
Session 10: Handwashing
7
Session 11: Diarrhea
8
Session 12: Training as tool for capacity building
on WASH
9
Session 13: Training facilitation methods &
techniques
10 Session 14: Training, mock exercise
11 Session 15: Action plan
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IV. Quality of training
(Note: For each statement given below, please check the response (√) that best describe your feedback
about specific aspect of training.)
S. No Particulars
1
Quality of resource persons
2
Relevance of contents covered
3
Training methodology
4
Quality of hand-outs provided
5
Time management of sessions
6
Accommodation
7
Training venue
8
Food
V. Suggestions
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For more information contact:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi-110016 | Tel: 91-11-4389166, Fax: 91-11-4389199
E-mail: info_hup@populationfoundation.in | website: www.populationfoundation.in
Disclaimer: This document is made possible by the support of the American people through the United States Agency
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