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Module IV WASH for urban health |
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Urban Health Training Module IV
Water, Sanitation and Hygiene
Promotion for Urban Health
Health of the Urban Poor (HUP) Program
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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, MeetaJaruhar, Biraja Kabi Satapathy, Anil
Kumar Gupta, Rakesh Kumar, Dr. Himani Tiwari, Shipra Saxena
Special inputs from:
Department of Health and Family Welfare, Department of Women and Child Development,
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 program facilitate and provides 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. A training module on Urban Water, Sanitation and Hygiene Promotion for the
frontline workers has been developed by HUP.
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CONTENTS
Preface
Message
Abbreviations
Chapter 1 Introduction
Chapter 2 An Overview of the Manual
2.1 Training Objective
2.2 Thematic Areas of Training
2.3 Target Audience for the Training
2.4 The Training Program
2.5 The Training Schedule for Frontline Workers
Chapter 3 Training Sessions
Day 1 Session 1
Registration
Session 2
Welcoming and Introduction
Session 3
Pretesting of Participants on Knowledge of WASH
Session 4
Perspective building on WASH
Session 5
Safe Drinking Water
Session 6
Drinking Water Safety at Source and Point of Use
Session 7
Safe Sanitation
Session 8
Summing up the learning from the first day
Day 2 Session 9
Recap of the first day
Session 10 Hygiene Behaviour
Session 11 Hand Washing
Session 12 Diarrhoea Prevention& Management
Session 13 Training Facilitation Methods and Techniques
Session 14 Role of ICDS and ASHA/ USHA Workers
Session 15 Forward Action Plan
Session 16 Administration of KAP and Feedback Questionnaires
Session 17 Valedictory
Chapter 4 Guidance to Facilitators
4.1 Do’s and Don’ts
4.2 Potential Trainers or Facilitators Profile
Annexure:
Annex 1
Guidelines from various Departments of the Government
Annex 2
Knowledge, Attitude and Practice (KAP) Questionnaire (pre training)
Annex 3
Hand-out- Safe Drinking Water
1
2
2
3
3
3
4
6
6
7
11
12
18
22
28
31
31
31
35
38
42
45
49
49
49
50
50
51
53
56
59
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Annex 4
Chlorination in Drinking Water
61
Annex 5
Description on Various Drinking Water Supply Source
63
Annex 6
Hand-out- Chlorination in Drinking Water
66
Description on various drinking water supply source
Sanitary inspection forms
Annex 7
Safe Sanitation
75
Annex 8
Hand-out- Safe Sanitation
77
Urban sanitation / toilet models
Annex 9
Snakes & Ladders Game
81
Annex 10 Hand-out- Hygiene
82
Annex 11 Hand-out-Hand Washing
83
Annex 12 Hand-out- Diarrhoea Management
85
Annex 13 Training Feedback Questionnaire
86
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ABBREVIATIONS
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
NUHM
OBC
ORS
PFI
PH
PHED
PPCP
: 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 Slum 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
: National Urban Health Mission
: Other Backward Classes
: Oral Rehydration Salt
: Population Foundation of India
: Physically Handicapped
: Public Health and Engineering Department
: Public Private Community Partnership
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PPP
RAY
RC
RCH
RO
SC
ST
SUHM
TA
THM
TSS
UIDS
UIDSSMT
UIG
UHFWC
ULBs
UNICEF
USAID
USHA
VBD
WASH
W&CD
WHO
: 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
: 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 countries. In India, about 1,000 under five deaths per day are caused
by diarrhea. About 31 percent of India’s population (377 million) lives in urban areas and among
them about 93 million (25 percent of urban population) live in urban slums 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 concerned 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 well-being
National and state
specific guidelines
Program implementation
by states/ULBs
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).
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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 important 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.
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.
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2.2 Thematic Areas of the Training
Safe drinking water, Safe sanitation, Hygiene behavior, 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 has 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.
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2.5 Training Schedule for Frontline Workers of State Departments, Donors, NGOs and CBOs
Duration: 2 days
Day Session
Session 1
Table 2.1: Training Schedule
Time
Topic/ Sub-topic
Methodology
09:30 am - 10:00 am Training participants registration
Training material
Registration
sheets/diary
Session 2
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 - 11:15 am Tea Break
Session 3
11:15 am - 11:30 am Administering KAP questionnaire on Response by each
WASH& training facilitation.
participant on a
questionnaire.
KAP questionnaire
Session 4
11:30 am - 1:00 pm
Perspective building on WASH
• Disease mapping
• F Chart
• Health pyramid
• Potty mapping
Guided plenary
discussion
White board
Marker pen
Chart papers
Bold marker pen
1:00 pm - 2:00 pm Lunch Break
Session 5
2:00 pm - 3:00 pm
Safe Drinking Water (activities/
games and situation analysis)
• What is safe drinking water?
• Safe sources of drinking
• Impact of water quality on health
Game-based group
discussion/
Presentation/
guided plenary
discussion
Chart papers
Bold marker pen
Adhesive/paper tape
White board marker pen
Session 6
Session 7
Session 8
3:00 pm - 4:00 pm
4:00 pm - 4:15 pm
4:15 pm - 5:15 pm
5:15 pm - 5:30 pm
Drinking water safety at source and
at point of use
• Source protection(sanitary
inspection and survey)
• Safe water handling
• Water purification
Large group discussion White board marker pen
Tea Break
Safe sanitation
• Present status and why?
• Sanitation options
• Economic cost of sanitation
• Myths and doubts about individual
household (IHL)latrines
• Impact and outcomes of safe
sanitation
(Activities/ games and
situation analysis)
Chart papers
Bold marker pen
Adhesive/paper tape
White board Marker pen
Summing up of Day I
Large group discussion White board marker pen
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Day Session
Session 9
Time
9:30 am - 9:45 am
Table 2.1: Training Schedule
Topic/ Sub-topic
Methodology
Recap
Presentation by
selected participants
Training material
Chart papers
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
Soap
Water
11:45 am - 12:00 am Tea Break
Session 12
12:00 noon - 1:00 pm
Diarrhea prevention and
management
• Diarrhea as a health issue arising
out of WATSAN problems.
• Prevention measures.
• Management
Guided plenary
discussion
White board marker pen
1:00 pm - 2:00 pm Lunch Break
Session
2:00 pm - 3:00 pm
Training facilitation methods &
Large group discussion
techniques
• Lecture/large group discussion
method.
• Case study method.
• Focused group discussion method.
• Do's & Don'ts for facilitating
training.
White board marker pen
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 discussion
Chart papers
Bold marker pen
Adhesive/paper tape
White board marker pen
4.00 pm - 4.15 pm Tea Break
Session 15 4:15 pm - 4:45 pm Forward action plan
Large group discussion Chart paper
Bold marker pen
Adhesive/paper tape
Session 16
4:45 pm - 5:10 pm
Administering KAP questionnaire on Response by each
WASH & training facilitation
participant on a
Training feedback sheet
questionnaire
KAP questionnaire
Training feedback sheet
Session 17 5:10 pm - 5:30 pm Valedictory
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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/
Company/
Agency name
Designation
Place of
posting
Phone
number
Email ID
Signature of the Training Coordinator
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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 favorite 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
favorite animal. Below this ask them to put a pet name for their favorite animal. Then ask them
to put up the flash cards with the name of the animal on top and the characteristics below on a
wall:
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Lion
Rabbit
Parrot
Powerful
Peaceful
Talkative
OR
OR
Royal
Meek
Colorful
Strong
Frisky
Cheerful
Sher Khan
Lajo
Mithu
Once everyone has done this, the participants will be asked to introduce themselves in the
following manner:
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 name Sher 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.
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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.
Table 3.2: SIGNATURE SHEET
B
I
N
G
O
Speaks three
languages
Not married
Loves reading
Eat chocolates
daily
Washes hands
before and after
meals
Has four cups
of tea while
working
Has three kids
Plays the guitar Doesn't drink
tea or coffee
Brushes teeth
thrice a day
Worked in three Has a pet at
organisations home
Paints
Likes ice cream Loves to sleep
Uses more than Lives in a joint Sings
three Sims
family
Vegetarian
Does not like to
exercise
Never flown in a Not afraid of
plane
snakes
Does not have Has a car
a mobile
Writes poetry
Does not like
listening to
music
Likes having
panipuri
Does not like
eating fruits
Hates cooking
Hates cleaning
the house
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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 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 to
liven up the environment and ease any initial inhibitions. This would also help in creating a great
degree of comfort among participants. The trainer must also participate in the game.
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 3.4: 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 with the trainee group. Here the trainer should also simultaneously try to
categorize the learning expectations into different categories based on 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 Category-1 Category-2 Category-3 Category-4
learning need to emerge from the
exercise. They would be most Flash
probably related to:
Card
Flash
Card
Flash
Card
Flash
Card
WASH definition and conceptual Flash
understanding
Card
Health concerns related to WASH
Interventions/activities in the area of
Flash
Card
WASH
Flash
Card
Flash
Card
Flash
Card
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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.
Objective articulation: Once the expectations of the participants are established, the trainer
should move ahead to the objectives of the training.
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.
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.
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 counterparts. The most visible face of urban poverty,
microcosms of squalor and deprivation amidst a sea of plenty, is visible in slums. 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
1. Understand linkages between health and WASH.
2. Knowledge about WASH following F-diagram.
3. Know about the importance and prioritization of hygiene determinants using the health
pyramid.
4. 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.
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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 dwellers.
Inadequate provision of safe drinking water, improper disposal of human waste, and lack of
adequate systems for disposal of sewage and Figure 3.3: Poor environmental hygiene
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.
Figure 3.4: Unsafe/ Open disposal of water
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 path.
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.
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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 studies 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.
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The F-Diagram
Most diseases which result in diarrhea are spread by pathogens (disease causing organisms)
found in human excreta (feces and 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 eggs. 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 or when small children are
crawling, playing on the ground or when adults clean a child's faeces.
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.
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Preventive Measures
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
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.
Figure 3.6: F Chart
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.
Life
Saving
Behaviors
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.
Health Improving
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.
Aesthetic Behaviors
Source: Hygiene Promotion Manual, WaterAid, 1999
Aesthetic behavior is that which makes a person
bright and beautiful. For example, behavior such as
combing of hair or wearing good clothes, anal
cleansing with water, rinsing the mouth after meals,
washing hands after eating.
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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.
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.”
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.
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Box 3.5: Understanding water supply in
urban areas
Figure 5.1: Tanker water
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.
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.
The discussion points from the trainer should focus on the following:
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What is Safe Drinking Water?
Figure 5.2: A ground level storage tank
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 usable for domestic
purposes. It is important for frontline workers to educate
the community on safe drinking water.
Box 3.6: Drinking water quality typically fall under two categories:
Chemical/physical - Chemical/physical parameters include heavy metals, trace organic compounds,
total suspended 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.
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.
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
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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 water and 83 percent have
access to any type of sanitation facility. The coverage is not reflected in terms of reduction in burden of
diseases. Table 3.4 depicts the health concerns that have risen due to water contamination.
Table 3.4: Morbidity Trends of Water-related Diseases
Sr.
Disease
Morbidity in Urban India (no. of cases)
2001
2009
1.
Diarrhea
9.28 million
11.98 million
2.
Malaria
20.5 million
1.56 million
3.
Viral Hepatitis
1.49 lakh
1.24 lakh
4.
Cholera
4178
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).
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Fung
Bacteria
Helminthes
Protozoa
Virus
Table 3.5 below depicts the diseases that can occur in humans due to pathogens.
S. No.
1.
2.
3.
4.
Table 3.4: Morbidity Trends of Water-related Diseases
Category
Waterborne
Water washed
Water based
Water related
Example
Diarrheal disease
Cholera
Dysentery
Typhoid
Infectious hepatitis
Diarrheal disease
Cholera
Dysentery
Trachoma
Scabies
Skin and eye infections
Acute Respiratory Infections (ARI)
Schistosomiasis
Guinea worm
Malaria
Onchocerciasis
Dengue
Fever
Gambian sleeping sickness
*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.
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 sanitary assessment and safe handling of water.
} To educate trainees on various methods of drinking water treatment at point of use.
} To educate trainee on the need and process of sanitary inspection and survey.
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Method for session moderation
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.
Figure 6.1 : Tubewell
The discussion should focus on the following aspects:
} Source protection / Sanitary Assessment
} 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 feces 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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Sanitary Inspection
Sanitary inspection is an on-site inspection of a water supply to identify actual and potential
sources of contamination that pose potential danger to the health and well being of the
consumer. The physical structure and operation of the system and external environment such as
latrine location are evaluated. This information can be used to select appropriate remedial
action to improve or protect the water supply.
Sanitary inspections can be considered for the following:
} All new sources of water before commissioning.
} Once the source is operational, it should be done on a regular basis.
} When water quality testing results of a particular source shows bacteriological
contamination.
} Under emergency conditions, such as onset of epidemic diseases, inspection should take
place immediately.
Sanitary inspection forms:
Inspection should be carried out by a suitable trained person using a simple clear report form.
These forms consist of a set of questions which have Yes / No answers. The questions are
structured so that yes answers indicate that there is a risk of contamination and no answers
indicate that the particular risk is absent. Each yes answer scores one point and no answer zero
point. At the end of the inspection the points are added up and based upon the total points
scored, the data could be expressed in terms of relative risk. The higher the total point scored,
the greater is the risk of contamination.
Involvement of various stakeholders in sanitary inspection process and use of the result:
The result of sanitary inspection and the remedial actions that need to be taken to improve
conditions should be discussed with the community. It’s even better if community members are
trained and are involved in carrying out the sanitary inspections by themselves. Information
gathered also need to be shared with the agency responsible for providing water and health
services. Frontline worker or person responsible for sanitary inspection should always try to
inform the local community representatives in advance of the sanitary inspection date and time
of visit. It’s better if community members or representatives sign the report.
Sanitary survey:
Some sanitary inspection should be done in conjunction with water quality testing. This is called
a sanitary survey. So two principal activities are involved in the sanitary survey, one is sanitary
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inspection and other is water-quality analysis. Inspection identifies potential hazard and while
water-quality analysis indicates whether contamination is occurring and, if so, its intensity. It is
to be noted that any sanitary survey report which suggests that serious risks exist need to be
officially logged and acknowledged, and follow-up action to be taken by the appropriate agency
(water supply or surveillance agency). Sanitary inspection of supplies over a period of years
provides a long term perspective and assists in the identification and minimisation of risks
caused by deterioration in any aspect of the supply.
Functions of Sanitary Inspection Report
} Identification of potential sources and points of contamination of water supply
} Quantify the hazard attributed to the sources and supply
} Provide a clear picture of explaining the hazards to the user
} Provide a clear guidance for the remedial action required to protect and improve the supply
} Availability of raw data for use in systematic, strategic planning for improvement in quality water
supply and minimising the risk
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 using hands to remove the excess water.
Figure 6.2: Covered Vessel
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 your 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 6.3: Use of ladle for safe drinking water
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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 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.
Figure 6.4: Testing Water Quality for fitness for consumption
Ready to use medium
Fit for drinking
Unfit for drinking
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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 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.
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.
Figure 6.7: Chlorination
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, a small 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 3.9 will 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 group and 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:
Figure 7.2: Open Defecation
“The means that hygienically separate human
excreta from human contact and hence reduces
health risks to humans.”
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.
Sanitation Options
Typically, in urban areas, the available
sanitation options include:
Individual household toilets: Normally found in
households. Only a small proportion of these in
urban poor settlements are connected through
sewers. In most cases in the slums, toilets
constructed are pour flush toilets with a septic
tank or leach pit. The maintenance of such
toilets is entirely the responsibility of the
household.
Figure 7.3: Sanitation Options
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Toilets in public/private institutions (for example,
government/private offices, schools, anganwadi
centers (AWCs), hospitals, markets buildings, bus-
stands, railway stations, etc.): These type of toilets are
mainly for people who are directly engaged in the
activities of the public or private institutions.
Maintenance of such toilets rests entirely on the
institution, which owns the facility.
Public/community toilets: These are public facilities
normally constructed by urban local bodies (ULBs) such
as municipal corporations / municipalities / NACs, local
groups or private entities (for example, Sulab
International). The primary purpose of such facilities is to provide sanitation facilities in public places or in
areas where the population cannot afford individual household toilets or has space constraints.
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 Figure 7.4:
practices facilitate transmission of vector-borne diseases, including diarrhea and a Disease symptoms
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 )
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, 2006) The economic toll is also significant in
terms of indirect losses such as water treatment costs, reduced school attendance, inconvenience,
and wastage of time.
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.
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SESSION 8: SUMMING UP THE LEARNING FROM THE FIRST DAY
Session 8: Summing up the learning from the first day (15 minutes)
This session marks the wrapping up of the first day of work of training.
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.
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.
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 the 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.
The trainer should select five volunteers from the trainee group to play the game. The game
should ideally take 20-30 minutes.
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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.
Box 3.10: The Snakes &Ladders Game
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 then 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?
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
Figure 8.2: Bathing
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”.
Regular bathing/showering, hand washing, and good general personal hygiene can reduce the risks of
self-infection.
Figure 8.3: Nail Cutting
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.
Cutting nails regularly with blade/scissors/nail cutter reduces the risk of infection.
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.
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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. They are then ready to be used again.
Some relevant points to ensure that menstrual management is supported by schools:
} 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. Keep old newspapers/waste paper ready to wrap the used 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.
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
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} 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 the Urban 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.
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
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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.
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?
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,
Figure 11.2:
and viruses such as rotavirus and norovirus. For example, a person with Need for Handwashing
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 feces or before
touching food.
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Following are events where handwashing must be followed as a thumbrule:
} After using the toilet or disposing feces.
} After changing babies’ nappies and disposing their
Figure 11.4: Disposing feces
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.
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: Diarrhea Prevention and Management (60 minutes)
Among these waterborne diseases, diarrhea is the only one that can be managed at home while the
rest require consulting medical professionals. Also, severe diarrhea may still require medical help.
Given the large incidence of diarrheal episodes and its possible management at home, the current
section deals with details of diarrhea prevention 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 diarrhea prevention measures.
} To inform participants on diarrhea management.
Waterborne Diseases
Figure 12.1:
Child suffering from water borne disease
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.
Category of Disease
Table3.6: Waterborne Diseases
Disease
Brief description of category
Fecal-Oral
Diseases
Intestinal Worms
Diarrhea
Cholera
Giardia
Amoebic dysentery
Typhoid
Hepatitis
Polio
Hookworm
Roundworm
Generally contracted through the ingestion of
fecal contaminated 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.
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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 numbers.
Method for session moderation
This session targets the supply of specific inputs on diarrhea prevention 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:
} Diarrhea as a health issue arising out of the water and sanitation.
} Prevention measures.
} Management of diarrhea.
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?
} Diarrhea is 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 dangerous?
} It results in dehydration and ultimately death.
} The net result is malnutrition.
} Diarrhea occurs so often that people do not take it seriously. But diarrhea can 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 diarrhea because 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 diarrhea is due to fecal contamination.
} The following are the causes of diarrhea:
} Using dirty/unsterilized feeding bottles which carry germs.
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} Consumption of unsafe water.
} Eating unhygienic foods like eating spoilt food or food that is infested with flies.
} Defecating in the open, for example, in the fields where the feces may come in contact with humans
through vegetables; defecating near houses, where flies may carry the germs and spread them by
sitting in the food; defecating near water sources; contaminating the water source; no handwashing
causing the feces to 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 diarrhea happens through contact with the virus/bacteria mentioned above.
Measures to reduce transmission emphasize the following practices:
} Safe and improved water supply.
Figure 12.2: Open defecation
} 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.
Anganwadi workers and urban ASHAs/USHAs can play an important role in preventing diarrhea by
conveying these messages thus reducing the transmission of the virus/bacteria, detailed ahead.
Management of Diarrhea
Diarrhea management 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 reduced 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 diarrhea has lasted over two days.
} The child is over a year old and the diarrhea has lasted more than five days.
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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.
Key steps in preparation of ORS:
Figure 12.3: How to prepare 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.
} 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 moderation
Figure 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 Communication 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, situations and 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.
} The trainer should be able to analyze the learning needs of the trainees and logically pursue the
learning process.
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Communication
} The trainer should have a strong command over his/her language and should be able express
himself/herself lucidly.
Figure 13.2: participative training
} 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 documents
and reports.
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.
} 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.
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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.
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
Figure 13.3: Adult Learning
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
}
} Small group discussion/FGD
}
(to explore the issue further)
} Collective analysis
}
Individual reflection
Extract insights
Summarization
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.
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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.
SESSION 14: ROLE OF ANGANWADI, URBAN ASHA/ USHA WORKERS
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/USHAs in 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.
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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 of 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
} 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
Key WASH messages for ICDS are:
Washing hands with soap at critical times can reduce the risk
of diarrheal diseases by 42 - 47 percent.
Figure 14.1: Safe practices in AWCs
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.
} Water gets contaminated more at point of use than at
source.
} Use of a sanitary latrine.
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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.
Figure 14.2: Safe practice of
serving Mid Day Meals
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 are the tertiary
hospitals.
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 center in their
respective areas. Urban health and family welfare centres offer MCH, child health and other services.
Convergence Role
Health and ICDS have a role complementing each other. The following table lists the same:
Services
Supplementary
Nutrition
Table (7 ) : Converging roles of Health and ICDS
Target Group
Service
Provided by
Proposed Services Proposed WASH
for MAS
component that
and USHA
may be covered
Children below 6 years:
Pregnant & Lactating
Mother (P&LM)
Anganwadi Worker
and Anganwadi
Helper
+ MAS/ USHA
+ MAS/ USHA
Facilitate in listing
Diarrhea
management
Food Hygiene
Immunization*
Children below 6 years:
Pregnant & Lactating
Mother (P&LM)
ANM/MO
+ MAS/ USHA
Handwashing
Cleanliness
Health Check-up*
Children below 6 years:
Pregnant & Lactating
Mother (P&LM)
ANM/MO/AWW
+ MAS/ USHA
Convergence for
JSY scheme
Referral Services
Children below 6 years:
Pregnant & Lactating
Mother (P&LM)
AWW/ANM/MO
+ MAS/ USHA
Pre-School Education Children 3-6 years
AWW
+ MAS/ USHA
School Hygiene
promotion
Nutrition & Health
Education
Women (15-45 years)
AWW/ANM/MO
+ MAS/ USHA
(Register updation
at slum level)
Modules on safe
water, safe
sanitation to aid
reduction of WASH
related illness
Identification of Target
Groups*
AWW/ANM
+ MAS/ USHA
Health and Nutrition
Day
AWW/ANM
Key messages on
WASH
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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 for 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.
} 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.
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.
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.
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} 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:
} 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/facilitator should be able to make the adult participant think and activate his
brain.
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} 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.
} Read out quotes from the 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 six decades since independence the country has recorded significant economic
growth but access to and availability of safe water and sanitation remains a 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.
1
2
3
4
Reference Document
Reference Points on WASH
National Water Policy 2002
Ministry of Water Resources,
Government of India
Adequate safe drinking water facilities should be
provided to the entire population, in both urban and
rural areas.
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.
Draft National Water Policy, 2012
Ministry of Water Resources,
Government of India
Recognizes the right to WATSAN.
The central, state and local bodies must ensure a
minimum 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.
National Health Policy, 2002
Ministries of Health and Family
Welfare, Government of India
The attainment of improved health levels would be
significantly dependent on population stabilization,
as also on complementary efforts from other areas of
the 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 waterborne diseases
by 2010 is one of the objective of the health policy.
Draft National Urban Health Mission Aims to address the health concerns of the urban
(2008–2012)
poor through facilitating equitable access to
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S. No.
4
5
6
7
Reference Document
Reference Points on WASH
Urban Health Division, Ministry of
Health and Family Welfare,
Government of India
available health facilities by rationalizing and
strengthening the existing capacity of health
delivery for improving the health status of the urban
poor.
It focuses on establishing synergies with programs
of similar objectives like Jawaharlal Nehru Urban
Renewal Mission (JnNURM), Swarna Jayanti
Shahari Rozgar Yojana, ICDS.
National Nutrition Policy, 1993
Department of Women and Child
Development, Ministry of Human
Resource Development,
Government of India
Undernutrition in urban areas is a major concern. It
says the status of urban slum dwellers in India is
almost as bad as that of rural poor.
The children of urban slums dwellers are
nutritionally the most fragile. One of the causes may
be poor sanitary condition.
National Policy for the
Empowerment of Women, 2001
Department of Women and Child
Development, Ministry of Human
Resource Development,
Government of India
Special attention will be given to the needs of
women in the provision of safe drinking water,
sewage disposal, toilet facilities and sanitation
within accessible reach of households, especially in
rural areas and urban slums.
Women’s participation will be ensured in the
planning, delivery, and maintenance of such
services
National Policy for Urban Street
Vendors,2009
Ministry of Housing and Urban
Poverty Alleviation,
Government of India
Provision of civic facilities including provision of
drinking water and public toilets at vending
zones/vendors market.
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Table A2:Various Schemes and Programs on WATSAN
S. No.
1
Name of the Schemes and
concern Ministry
Provisions
Jawaharlal Nehru
The Government of India’s JnNURM targets 63 key cities
National Urban
and urban areas, focusing on services to the poor as one
Renewal Mission
of its explicit missions. It includes two sub-missions: the
(JnNURM)
Urban Infrastructure and Governance (UIG) and the Basic
Services to Urban Poor (BSUP). Besides, two other
Ministry of Urban
reform-driven schemes - Urban Infrastructure Development
Development
Scheme for Small and Medium Towns (UIDSSMT) and
Integrated Housing and Slum Development Programme
(IHSDP) - were included under JnNURM.
The BSUP seeks to provide a garland of seven
entitlements / 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 (ILCS)
Ministry of Housing &
Urban Poverty
Alleviation
The scheme is specifically designed to cover the
economically weaker section of society. It constructs or
converts low cost sanitation units through sanitary two pit
pour flush latrines with superstructures and appropriate
variations to suit local conditions. For those who practice
open defecation, new toilets are built under the scheme. The
central government shares 75 percent of the cost while the
state government contributes 15 percent. Beneficiaries
contribute the remaining 10 percent.
3
Rajiv AwasYojana
(RAY)
Ministry of Housing &
Urban Poverty
Alleviation
The scheme is being implemented from 2009 to 2016. It
aims to provide central government support to states that
attempt to assign property rights to slum dwellers. 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
Tube well
Ponds/water bodies with unrestricted access (human, animals, etc.)
Covered well
3.2 Identify below the factors that can contaminate sources of drinking water. (
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 standpost/tube well
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3.3 Identify the diseases that are caused due to contaminated water. ( .
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
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
Safe
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 Diarrhea is 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 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 is desirable.
When chlorine is applied to water prior to any treatment, the process is called pre chlorination.
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
chlorination.
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 form (gas, liquid, or
solid).
} You may be exposed to objectionable smelling and tasting water if the chlorine content is
higher than the recommended quantity.
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A. Procedure for chlorinating at household level:
} 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 gram weight 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.
} 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.
“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/).
“Manual on Water Supply and Treatment,” CPHEEO, 1999
(http://www.indiawaterportal.org/node/12574).
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ANNEXURE 5
DESCRIPTION ON VARIOUS DRINKING WATER SUPPLY SOURCE
Dug wells
Dug well is a traditional way of ground water extraction. Since it is difficult to dig beneath the
ground water table, dug wells are not very deep. Typically, they are only 10 to 30 feet deep.
Being so shallow, dug wells have the highest risk of becoming contaminated. In case of
traditional (open) dugwells, a sanitary inspection indicates the main causes of contamination
and how they can be eliminated through improvement. Improved dug wells require regular
monitoring to ensure that an adequate and safe water supply is maintained.
Open Dug well
Open dug wells are uncovered from top. Open or poorly covered well heads pose the most
common risk to well-water quality, since the water may then be contaminated by the use of
inappropriate water-lifting devices by consumers. The most serious source of pollution is faecal
contamination from latrines and septic tanks, resulting in increased levels of micro organisms,
including pathogens, thereby posing a high level of the risk to the consumer. The majority of
open dug wells are contaminated, with faecal coliforms, unless very strict measures are taken to
ensure that contamination is not introduced by the bucket.
Dug well with wind lass and partial cover
A windlass is a pulley fixed on a partially covered well at the top. The wind lass help to draw
water safely and hygienically through a bucket and a rope from the well. The water lifting device
should be carefully incorporated during casting the cover slab. A community dug well with a
windlass whereby one bucket is suspended over the well in a narrow opening is an improvement
on each individual using his or her own bucket.
Covered Dug well with hand pump
To minimize the likelihood of contamination, dug well are covered from the top with a concrete
slab and a hole at the centre to draw water through a hand pump. The top cover should stand
about a foot above the ground. After installation of the hand pump, it is important to seal the
hole in the centre of the cover to stop spilt water back into the well. Water quality is greatly
improved by the installation of a hand-pump and the fitting of a sanitary cover to an open dug
well, access being restricted by a lockable sanitary lid, which prevents any contamination of the
well by buckets.
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Hand-pumped tube wells
Ground water could also be extracted through a tube well in combination with either a
mechanical or a hand pump. A tube well with hand pump consists of a borehole (the source of
water); a platform with a drainage and soak away pit (protection from surface water infiltration
and contamination); and a hand pump (the water lifting device). In about 85% of cases, shallow
or deep tube wells with hand-pumps and proper sanitary protection will supply water that
contains few, if any, fecal indicator bacteria.
Tubewell with mechanical pump
Mechanical pumps are generally used to draw water from much greater depth through drilling a
borehole to reach deep aquifers. Water from deep boreholes is less likely to be affected by
pollutants originating from the land or surface waters and is normally free from microbiological
contamination. However, certain structural precautions are essential when wells and the
associated pumps are installed.
Protected spring
Exposed springs are vulnerable to contamination from human and animal activities. If a spring is
to be used as a source of domestic water, it should be of adequate capacity to provide the
required quantity and quality of water for its intended use throughout the year. It should be
protected to preserve its quality. The usual method of protecting springs is to collect the water
where it rises by enclosing the eye of the spring in a covered chamber or box with an outlet near
the bottom to allow water to flow away from the original site of the spring; in this way the
natural spring is disturbed as little as possible.
Rainwater collection
Rainwater harvesting is a technique of conserving rainwater where it falls without allowing
contamination to take place in the catchment and taking measures to keep that water clean.
Rainwater catchment includes unpaved areas such as parks, lawns, forests and paved surfaces
such as roof top, foot paths etc. Rooftop harvesting has been practiced since ages, and is a
convenient approach at household level in urban sector. Rainwater collected from clean house
roofs can be of better microbiological quality than water collected from untreated household
wells. A rainwater storage tank should be completely covered and well maintained.
Piped water supply
Piped water supply consists of a water lifting mechanism from source, a distribution network
through pipe lines and individual delivery points such as household piped supply, public and
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community stand posts. Properly treated water is generally supplied through piped network
and it is the most common water supply system in urban areas. Inspection of a piped supply
includes monitoring at source, reservoirs and distribution network. Sampling points should be
uniformly distributed throughout a piped distribution system.
Tanker Supply
Methods of providing drinking-water vary widely. They may include the use of tanker truck for
water delivery. Such methods of tanker water supply are common in the informal settlements
where there is no piped water supply or if the water supply does not meet the demands, mostly
in the dry seasons. In such cases, it must be ensured to use clean pipes to limit any
contamination at the source of collection. Proper cleanliness of the tankers should be
maintained.
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SANITARY INSPECTION FORMS
ANNEXURE 6
I. Type of facility: OPEN DUG WELL
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine within 10m of the well?
Y/N
2. Is the nearest latrine on higher ground than the well?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish) within 10m of the well?
Y/N
4. Is the drainage poor, causing stagnant water within 2m of the well?
Y/N
5. Is there a faulty drainage channel? Is it broken, permitting ponding?
Y/N
6. Is the wall(parapet) around the well inadequate, allowing surface water to enter the well?
Y/N
7. Is the concrete floor less than 1m wide around the well?
Y/N
8. Are the walls of the well inadequately sealed at any point for 3m below the ground?
Y/N
9. Are there any cracks in the concrete floor around the well which could permit water to enter the well?
Y/N
10. Are the rope and bucket left in such a position that they may become contaminated?
Y/N
11. Does the installation require fencing?
Y/N
Total score of risks......................./11
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-11 very high 6-8 high 3-5 intermediate 0-2 low
III. Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general
or
their authorized representative after the assessment of the risk from 1-11.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: OPEN DUG WELL WITH WINDLASSAND PARTIAL COVER
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine within 10m of the well?
Y/N
2. Is the nearest latrine on higher ground than the well?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish) within 10m of the well?
Y/N
4. Is the drainage poor, causing stagnant water within 2m of the well?
Y/N
5. Is there a faulty drainage channel? Is it broken, permitting ponding?
Y/N
6. Is the wall(parapet) around the well inadequate, allowing surface water to enter the well?
Y/N
7. Is the concrete floor less than 1m wide around the well?
Y/N
8. Are the walls of the well inadequately sealed at any point for 3m below? ground?
Y/N
9. Are there any cracks in the concrete floor around the well which could permit water to enter the well?
Y/N
10. Are the rope and bucket left in such a position that they may become contaminated?
Y/N
11. Does the well require a cover?
Y/N
12. Does the installation require fencing?
Y/N
Total score of risks......................./12
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-12 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general
or
their authorized representative after the assessment of the risk from 1-12.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: COVERED DUG WELL WITH HAND-PUMP
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine within 10m of the well and hand-pump?
Y/N
2. Is the nearest latrine on higher ground than the hand-pump?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish) within 10m of the hand-pump?
Y/N
4. Is the drainage poor, causing stagnant water within 2m of the cement floor of the hand-pump?
Y/N
5. Is there a faulty drainage channel? Is it broken, permitting ponding?
Y/N
6. Is the wall(parapet) around the hand-pump inadequate, allowing animals in?
Y/N
7. Is the concrete floor less than 1m wide around the hand-pump?
Y/N
8. Is there any ponding on the concrete floor around the hand-pump?
Y/N
9. Are there any cracks in the concrete floor around the hand-pump
Y/N
which could permit water to enter the hand-pump?
10. Is the hand-pump loose at the point of attachment to the base so that water could enter the casing?
Y/N
11. Is the cover of the well unsanitary?
Y/N
12. Are the walls of the well inadequately sealed at any point for 3m below ground level?
Y/N
Total score of risks......................./12
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-12 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-12.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: RAINWATER COLLECTIONAND STORAGE
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there any visible contamination of the roof catchment area (plants, dirt, or excreta)?
Y/N
2. Are the guttering channels that collect water dirty?
Y/N
3. Is there any deficiency in the filter box at the tank inlet (e.g. lacks fine gravel)?
Y/N
4. Is the any other point of entry to the tank that is not properly covered?
Y/N
5. Is there any defect in the walls or top of the tank( e.g. cracks) that could let water in?
Y/N
6. Is the tap leaking or otherwise defective?
Y/N
7. Is the concern floor under the tap defective or dirty?
Y/N
8. Is the water collection area inadequately drained?
Y/N
9. Is there any source of pollution around the tank or water collection area( e.g. excreta) ?
Y/N
10. Is the bucket in use and left in a place where it may become contaminated?
Y/N
Total score of risks......................./10
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-10 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-10.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: TUBEWELL WITH HAND- PUMP
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine within 10m of the hand-pump?
Y/N
2. Is the nearest latrine on higher ground than the hand-pump?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish,
Y/N
surface water)within 10m of the hand-pump?
4. Is the drainage poor, causing stagnant water within 2m of the hand-pump?
Y/N
5. Is the hand-pump drainage channel faulty? Is it broken, permitting ponding? Does it need cleaning?
Y/N
6. Is the fencing around the hand-pump inadequate, allowing animals in?
Y/N
7. Is the concrete floor less than 1m wide all around the hand-pump?
Y/N
8. Is there any ponding on the concrete floor around the hand-pump?
Y/N
9. Are there any cracks in the concrete floor around the hand-pump which could permit water to enter the well ?
Y/N
10. Is the hand-pump loose at the point of attachment to the base so that water could enter the casing?
Y/N
Total score of risks......................./10
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-10 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-10.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: FILLING STATIONS, TANKER TRUCKS,AND HOUSEHOLD TANKS
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine within 10m of the hand-pump?
Y/N
2. Is the nearest latrine on higher ground than the hand-pump?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish,
Y/N
surface water)within 10m of the hand-pump?
4. Is the drainage poor, causing stagnant water within 2m of the hand-pump?
Y/N
5. Is the hand-pump drainage channel faulty? Is it broken, permitting ponding? Does it need cleaning?
Y/N
6. Is the fencing around the hand-pump inadequate, allowing animals in?
Y/N
7. Is the concrete floor less than 1m wide all around the hand-pump?
Y/N
8. Is there any ponding on the concrete floor around the hand-pump?
Y/N
9. Are there any cracks in the concrete floor around the hand-pump which could permit water to enter the well ?
Y/N
10. Is the hand-pump loose at the point of attachment to the base so that water could enter the casing?
Y/N
Total score of risks......................./10
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-10 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-10.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: DEEP BOREHOLE WITH MECHANICAL PUMP
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there a latrine or sewer within 15-20m of the pump house?
Y/N
2. Is the nearest latrine a pit latrine that percolates to soil, i.e. unsewered?
Y/N
3. Is there any other source of pollution ( e.g. animal excreta, rubbish, surface water)within 10m of the borehole? Y/N
4. Is there an uncapped well within 15-20m of the borehole?
Y/N
5. Is the drainage area around the pump house faulty? Is it broken, permitting ponding and /or leakage to ground? Y/N
6. Is the fencing around the installation damages in any way which would
Y/N
permit any unauthorized entry or allow animals access?
7. Is the floor of the pumphouse permeable to water?
Y/N
8. Is the well seal unsanitary?
Y/N
9. Is the chlorination functioning properly?
Y/N
10. Is chlorine present at the sampling tap?
Y/N
Total score of risks......................./10
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-10 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-10.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: PROTECTED SPRING SOURCE
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is the spring source unprotected by masonry or concrete wall or spring
Y/N
box and therefore open to surface contamination?
2. Is the masonry protecting the spring source faulty?
Y/N
3. If there is a spring box, is there an unsanitary inspection cover in the masonry?
Y/N
4. Does the spring box contain contaminating silt or animals?
Y/N
5. If there is an air vent in the masonry, is it unsanitary?
Y/N
6. If there is an overflow pipe, is it unsanitary?
Y/N
7. Is the area around the spring unfenced?
Y/N
8. Can animals have access to within 10m of the spring source?
Y/N
9. Does the spring lack a surface water diversion ditch above it, or ( if present) is it non-functional?
Y/N
10. Are there any latrine uphill of the spring?
Y/N
Total score of risks......................./10
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 9-10 very high 6-8 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-10.
Signature of surveying people: .............................
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SANITARY INSPECTION FORMS
I. Type of facility: PIPED DISTRIBUTION
1. General information:
I. City/Town ................................................................................................................................................................
ii. District.....................................................................................................................................................................
iii. Health centre...........................................................................................................................................................
iv. Slum name ..............................................................................................................................................................
v. Ward No...................................................................................................................................................................
2. Code no.......................................................... Address/ land mark of water facility ........................................................
3. Water authority / community representative signature.....................................................................................................
4. Date of visit.....................................................................................................................................................................
5. Water sample collected? .......................................................... if yes, Sample no..........................................................
6. Whether water is safe and can be useable?
(If water sample taken on H2Svial remain same after 24-48 hours and color not changed to black it is safe and useable)
II. Specific diagnostic information for assessment
Risk
Please mark yes or no for the answers of the following questions to assess the risk
1. Is there any point of leakage between source and reservoir?
Y/N
2. If there any pressure breaks boxes, are their covers unsanitary?
Y/N
If there is a reservoir:
3. Is the inspection cover unsanitary?
Y/N
4. Are any air vents unsanitary?
Y/N
5. Is the reservoir cracked or leaking?
Y/N
6. Are there any leaks in the distribution system?
Y/N
7. Is the area around the tapstand unfenced (dry stone wall and/ or fencing incomplete)?
Y/N
8. Does water accumulate near the tapstand (requires improved drainage canal)?
Y/N
9. Are there human excreta within 10m of the tapstand?
Y/N
10. Is the plinth cracked or eroded?
Y/N
11. Does the tap leak?
Y/N
Total score of risks......................./11
To calculate the risk at water source, please count all the “yes” marked in the response of the above mentioned questions
Contamination risk score: 10-11 very high 6-9 high 3-5 intermediate 0-2 low
III Results and recommendations
Suggestions regarding prevention and precautions were given to the community members in general or
their authorized representative after the assessment of the risk from 1-11.
Signature of surveying people: .............................
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SAFE SANITATION
ALWAYS USE CLEAN, CONCRETE TOILETS FOR GOOD HEALTH AND WELL-BEING
ANNEXURE 7
It is important not to defecate in the open because:
} When we defecate in the open the feces is 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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URBAN SANITATION/TOILET MODELS
ANNEXURE 8
Every toilet has two major parts- (a) Substructure and (b) Superstructure. A substructure
collects and stores excreta in a way that prevents harmful pathogens from being carried to a new
host. The superstructure is basically a room for housing the toilet. Substructure is technically
important as it provides safe disposal or reuse of human wastes. All the technical options are
meant for substructures only. Superstructure is basically meant to provide privacy of the toilet
and major technical inputs are not required for this component.
Sanitation systems could be:
} On-site, retaining wastes in the vicinity of the toilet in a pit, tank or vault.
} Off-site, removing wastes from the vicinity of the toilet for disposal elsewhere through
sewerage.
A. On-site Systems
Pour Flush Toilets with single leach pit
Features: Fecal matter is accumulated in an underground pit normally lined with open-jointed
brickwork or cement rings with holes to enable water and gases to percolate into the ground.
The pit may be located directly under the latrine superstructure or can be offset so as to enable
access for desludging. After defecation, the pan requires flushing with a few litres of water. The
water retained in the pan provides a seal against smell, flies and mosquitoes known as water seal.
Requirements: Care should be taken when using leach pits in situations where groundwater is
used for water supply. A minimum distance of 10 meters should be allowed between a leach pit
and the ground water source whether a well or hand pump to prevent any contamination of
water source. If unable to do so, then a sand barrier should be given in both the sides of the leach
pit and the bottom sealed with cement layer. Also the wall of the leach pit at the top should be
atleast 10cm above the ground level so that waste water or rain water does not go in. A junction
box/Diversion chamber will help in easy connection to a second pit if the first one gets filled.
Limitations: Impermeable soils such as clay or rock preclude the use of leach pits. A high water
table may also reduce the capacity of the soil to infiltrate wastewater. After the pit gets filled, the
pit needs to be closed and another pit needs to be created which entails labour and cost.
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Flush Toilet with offset Twin Pit
Features: Two underground chambers are provided to
Diagram 1: single leach peat latrine
hold fecal matter. These are normally away from the toilet
and should be at least 1 meter apart. A single pipe leads
from the toilet to a small diversion chamber, from which
separate pipes lead to the two underground chambers.
Faecal material is discharged to one chamber until it is full
of fecal sludge. After this period, the discharge is diverted
to the second pit. Just before the second chamber is full of
fecal sludge, normally after one year, the decomposed
contents of the first pit can safely be removed and used as organic fertilizer. The first pit can be
used again while the contents of the second pit decompose. Vent pipe is not required in the
leach pit as the gases also diffuse in the soil through the perforated structure of the pit.
Requirements: The pits should be lined with open-jointed brickwork or cement rings with holes,
similar to the single pit design.
When the first pit is full it should be left for at least twelve months, the period required for
adequate pathogen destruction.
Limitations: Householders may not use the pits alternately if they do not understand the system
properly, or may omit to leave the filled pit unused for a minimum period of one year so that the
contents degrade and become harmless.
The contents of the pit may not decompose safely when the double pits are too close to each
other without an effective seal between them, allowing liquids to percolate from one pit to the
other.
Diagram: 2 Offset twin leach pit toilet
Flush Toilet with Septic tank & Soakaway
Features: Waste from the toilet, and generally domestic
wastewater, is flushed into the settling chamber where it is
retained for at least 24hrs to allow settlement and
biological digestion.
Partially treated liquids then pass out of the tank and into
the subsoil drainage/soakaway system. Digested sludge
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gradually builds up in the tank and requires eventual removal by tanker. A vent pipe is required in
septic tanks for escape of gases.
Requirements: It should be ensured that the septage (sludge from septic tanks) is periodically
removed and transferred to another location for further treatment and final disposal by vacuum
tanker.
Limitations: Failures due to poor design and construction, and use of large amounts of
detergents or chemicals for cleaning of toilets may disturb the biochemical process in the tank.
Diagram: 3 Flush toilets with septic tank & soakaway
Community Toilet Block
Features: A community toilet block is a toilet
complex provided for a group of residents in a
community. Pour flush technology is generally
used in community toilet blocks. A community
toilet block could either be connected to
pit/septic tank or sewerage. Washing and bathing facilities are sometimes included in the block.
Communal toilet blocks are used primarily in low-income and informal settlements where
individual house connections are not feasible due to a lack of space or land tenure problems.
There are various management models of community toilet that has been attempted from
community managed to community control which ensures effective operations and
maintenance of the CT.
Requirements: Primary concern is ensuring that the number of seats in the CT is in accordance
to the population of the target area, keeping the toilet block clean; and maintaining proper
water supply. If the toilets are connected to septic tank/pits, desludging at regular intervals is
required. Proper safety and convenience of women, children, physically challenged and old age
people needs to be ensured.
Limitations: The main risk is failure of proper and regular maintenance of the complex so that it
becomes unsanitary and eventually falls into disuse.
People may be unwilling to pay the user charge and the facility is underused.
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B. Off-site Systems
Flush Toilets Connected with Conventional Sewerage
Features: Waste from the toilet, and possibly domestic wastewater, is flushed using significant
volumes of water into the sewer system for removal to a sewage treatment plant (STP) .
Requirements: Requires a reliable and uninterrupted household water connection and spatially
regular permanent settlements. Sewers and manhole chambers will occasionally require
structural repair and periodic cleaning of silts in the
Diagram: 4 Flush toilets with sewerage connection
sewer lines.
Limitations: Expensive and skilled manpower and
effective operation and maintenance is required for
sewers and the full functioning of the treatment
facility.
Not feasible in informal settlements where
excavation is difficult to lay conventional sewer
pipelines.
Source: Sanitation Technology Options, Sanitation for a Healthy Nation, National Sanitation Task Team,
Pretoria, 2002
References:
A guide to decision making: Technology options for Urban Sanitation in India, Water and Sanitation
Program, 2008
CPHEEO. 1993. Manual on Sewerage and Sewage Treatment of the Central Public Health and
Environmental Engineering Organization. Ministry of Urban Development.
Sanitation Technology Options, Sanitation for a Healthy Nation, National Sanitation Task Team, Pretoria,
2002
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SNAKES&LADDERS GAME
ANNEXURE 9
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9.8 Page 88 |
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HYGIENE
ANNEXURE 10
Health and hygiene are both connected. Poor hygiene leads to poor health and diseases. By
adopting good practices at different points of time to prevent germs 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 point of use.
} 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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HAND WASHING
ANNEXURE 11
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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DIARRHEA MANAGEMENT
ANNEXURE 12
Diarrhea is 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 to compared to adults.
Diarrhea can be caused by either virus or bacteria.
To prevent diarrhea from 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 we experienced the following: excessive thirst, very dry
mouth, very little or no urination; severe abdominal pain; severe rectal pain; blood in the stools,
the black stools; body temperature is over 39 degrees centigrade (102 degrees Fahrenheit). If
the child is aged three months to one year and the diarrhea has lasted over two days; if the child
is over one year of age and the diarrhea has lasted more than five days. Pregnant women with
diarrhea should 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 diarrhea at 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 soup 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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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 (ü on your choice.
ANNEXURE 13
Training objectives were achieved: Please put (ü 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 ü symbol)
S. No
1
2
3
4
5
6
7
8
9
10
11
Particulars
Session 2: Expectation mapping & objective articulation
Session 4: Introduction of WASH
Session 5: Safe drinking water
Session 6: Clean drinking water interventions
Session 7: Safe sanitation
Session 10: Handwashing
Session 11: Diarrhea
Session 12: Training as tool for capacity building on WASH
Session 13: Training facilitation methods & techniques
Session 14: Training, mock exercise
Session 15: Action plan
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IV. Quality of training
(Note: For each statement given below, please check the response (ü that best describe your
feedback about specific aspect of training.)
S. No
1
2
3
4
5
6
7
8
Particulars
Quality of resource persons
Relevance of contents covered
Training methodology
Quality of hand-outs provided
Time management of sessions
Accommodation
Training venue
Food
V. Suggestions
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IIHMR
JAIPUR
For more information please contact:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi-110016, Tel: 91-11-43894166, Fax: 91-11-43894199
E-mail: info_hup@populationfoundation.in, www.populationfoundation.in
This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The
contents are the responsibility of the Population Foundation of India and do not necessarily reflect the views of USAID or the United States Government