KOWLEDGE ATTITUDES AND PRACTICES ON SAFE COVERAGE OF

WATER, SANITATION AND HYGIENE: CASE STUDY OF CATHOLIC

RELIEF SERVICES SOUTH SUDAN

BY
MANON DAVID AWAN

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENT FOR THE AWARD OF POST GRADUATE DIPLOMA
IN WATER SANITATION AND HYGIENE TO THE STRATEGIA
NATHERLAND

i
 DECLARATION
Declaration by the Student
This research project is my original work and has not been presented to any other
college. No part of this research should be reproduced without my consent or that of
the Strategia Netherlands for Water Sanitation and Hygiene.

Name: _____________________Signature: _________________ Date____________

PGD/002/2021

Declaration of the Supervisor/Lecturer

This research project has been submitted for defense with my approval as the
Strategia Netherlands for Water Sanitation and Hygiene.

Name: _____________________Signature: _________________ Date____________

Lecturer Supervising

For and on behalf of the Strategia Netherlands for Water Sanitation and
Hygiene.

Name: _____________________Signature: _________________ Date____________

i
 DEDICATION
I sincerely dedicate this research project to my entire family for their encouragement
and support both financially and morally, God’s love for you shall endure forever.

ii
 ACKNOWLEDGEMENT
I humbly acknowledge God the father for the gift of grace and ability he has granted
me to fully concentrate in my studies, for his divine wisdom that he gave me to carry
on throughout this study. I am duly and deeply indebted to my research supervisor for
his positive criticism and dedicating his time and attention to enable me to come up
with this splendid piece of work.

I also thank Strategia Netherlands for Water Sanitation and Hygiene for the support
and service they have contributed towards my studies in the institution.

iii
 ABSTRACT
The purpose of this research project was to assess the coverage of water sanitation and
hygiene at household’s level.

iv
 TABLE OF CONTENT
DECLARATION………………………...……. ........................................................... i
DEDICATION .............................................................................................................. ii
ACKNOWLEDGEMENT ........................................................................................... iii
ABSTRACT ................................................................................................................. iv
TABLE OF CONTENTS ...............................................................................................v
ABBREVIATIONS ................................................................................................... Vii
OPERATIONAL DEFINITION OF TERMS ........................................................... viii

CHAPTER ONE
INTRODUCTION OF THE STUDY
1.1 Introduction ...........................................................................................................1
1.2 Background of the Study ......................................................................................1
1.3 Statement of the Problem ....................................................................................11
1.4 Objectives of the Study .......................................................................................13
1.5 Research Questions .............................................................................................13
1.6 Significance of the Study ....................................................................................14
1.7 Limitations of the Study......................................................................................14
1.8 Scope of the Study ..............................................................................................15

CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction ........................................................................................................16
2.2 Review of Theoretical Literature .......................................................................16
2.3 Review of Critical literature................................................................................36
2.4 Summary .............................................................................................................37
2.5 Conceptual Framework .......................................................................................38

v
CHAPTER THREE
RESEARCH DESIGN AND METHODOLOGY
3.1 Introduction ........................................................................................................41
3.2 Study Design ......................................................................................................41
3.3 Target Population ................................................................................................41
3.4 Sample Design ....................................................................................................41
3.5 Data Collection Procedures.................................................................................42
3.6 Data Analysis Methods .......................................................................................43

CHAPTER FOUR
DATA, ANALYSIS, PRESENTATION AND INTERPRESENTATION OF
FINDINGS
4.1 Introduction .................................................................................................... …...44
4.2 Presentation of Findings ............................................................................. …......44
4.3 Summary of Data Analysis ............................................................................ …...44

CHAPTER FIVE
SUMMARY OF FINDINDGS, CONCLUSION AND RECOMMENDATIONS
5.1 Introduction .................................................................................................... …...61
5.2 Summary of the Study Findings .................................................................. …...61
5.3 Conclusion ..................................................................................................... …...62
5.4 Recommendations .......................................................................................... …...62
5.5 Suggestion for Further Study ........................................................................ …...63
REFERENCES ............................................................................................................ 64

APPENDICES
Appendix I Consent form------------------------------------------------------------------- i
Appendix II Questionnaire------------------------------------------------------------------ ii

vi
LIST OF ABBREVIATIONS
C4D community for development
CFR case fatality rate
CLTS community led total sanitation
CRS Catholic Relief Services
CU5 children under 5 years of age
FEA field extension agent
FFP Office of Food for Peace
FGD focus group discussion
IDP internally displaced person
HH households
HHP home hygiene promoter
HHS Household and Health Survey
IEC information education and communication
JFSP Jonglei Food Security Program
KAP knowledge attitude and practices
MEAL monitoring evaluation accountability
NFI non-food item
NGO non-governmental organization
ORS oral rehydration solution
PoC protection of civilians
RiA required if applicable
SCF save the Children Federation
UN United Nations
UNDP United Nations Development Program
USAID United States Agency for International Development
VIP ventilated improved latrine
WASH water sanitation and hygiene
WASHCO water sanitation and hygiene committee
WHO World Health Organization
WPUC water point user committee

vii
OPERATIONAL DEFINITION OF TERMS

Water is a transparent and nearly colorless chemical substance that is the main
constituent of Earth's streams, lakes, and oceans, and the fluids of most living
organisms. Its chemical formula is H2O, meaning that its molecule contains one
oxygen and two hydrogen atoms, that are connected by covalent bonds.

Sanitation is the hygienic means of promoting health through prevention of human

contact with the hazards of wastes as well as the treatment and proper disposal of
sewage or wastewater. Hazards can be physical, microbiological, biological or
chemical agents of disease.

Hygiene is a set of practices performed for the preservation of health. According to

the World Health Organization (WHO), "Hygiene refers to conditions and practices
that help to maintain health and prevent the spread of diseases."
Improved drinking water source: a source which has been constructed to provide
adequate protection from outside contamination.
Improve sanitation facilities: facilities that hygienically separate human excreta
from human contact.
Safe water chain: a chain of activities aimed at preventing contamination of water
sources, treating the water to reduce or remove contamination that could be present to
the extent necessary to meet the water quality targets; and preventing re-
contamination during storage, distribution, and handling of drinking water.
Diarrhoea: the passing of three or more loose or liquid stools per day.
Water purification: the process of removing undesirable chemicals, biological
contaminants, suspended solids, and gases from contaminated water.
Ventilated improved pit (VIP) latrine: a pit latrine with a cleanable slab and
improved ventilation.
Adequacy of water by source: For this survey adequacy means availability of 20
litres of water person per day for drinking and bathing purposes.
Community led total sanitation: an approach to achieve sustained behaviour change
in mainly rural people by a process leading to spontaneous and long-term
abandonment of open defecation practices by provoking shame and disgust about
poor sanitation

viii
 CHAPTER ONE

INTRODUCTION OF THE STUDY

1.1 Introduction
The chapter presents the background of the study, statement of the problem,
objectives of the study, significance, limitations, and the scope of the study. This
brings about good understanding of what the study is expected to attain in the long
run.

1.2 Background of the study

Water is a transparent and nearly colorless chemical substance that is the main
constituent of Earth's streams, lakes, and oceans, and the fluids of most living
organisms. Its chemical formula is H2O, meaning that its molecule contains one
oxygen and two hydrogen atoms, that are connected by covalent bonds.

Sanitation is the hygienic means of promoting health through prevention of human

contact with the hazards of wastes as well as the treatment and proper disposal of
sewage or wastewater. Hazards can be physical, microbiological, biological, or
chemical agents of disease.

Hygiene is a set of practices performed for the preservation of health. According to

the World Health Organization (WHO), "Hygiene refers to conditions and practices
that help to maintain health and prevent the spread of diseases."

In South Sudan, Jonglei State has the Resilience Food Security Program (RFSP)
which is funded by United States agency for international development (USAID)
Food for Peace (FFP) and implemented by Catholic Relief Service (CRS) and Save
the Children Federation (SCF) in partnership with the government of Jonglei State,
South Sudan. RFSP aims to support communities in strengthening food security in
nine counties (Bor, Twic East, Duk, Uror, Ayod, Akobo, Nyirol, Pibor and Fagak)
with a package of interventions including resilience and recovery activities, provision
of food assistance (conditional and unconditional) and non-food items (NFIs),
preventive nutrition and WASH.

1
The program targets conflict affected and vulnerable households in the nine counties.
RFSP has carried out assessments and rehabilitation of boreholes and established and
trained water WPUCs and provided spare parts and rehabilitation tool kits for
borehole maintenance. RFSP also trained home hygiene promoters (HHPs) and school
WASH clubs. RFSP carried out hygiene promotion activities in the community
through awareness raising, house to house visits and community group discussions. In
schools RFSP carried out hygiene promotion activities through role plays, dramas,
poems, songs, school compound cleaning campaigns and quizzes and competitions.

In 2015 South Sudan has been negatively impacted by water borne diseases such as
cholera, acute watery diarrhoea, and hepatitis E.

Cholera is endemic in South Sudan and historically outbreaks have occurred along
major rivers in the dry season as well as during the rainy season. IDP and refugee
camps and other areas with high concentrations of people have a higher risk of
cholera outbreaks. Between 2006 and 2009, South Sudan experienced major cholera
outbreaks in many parts of the country where safe water supply, sanitation, food
safety and hygiene services were extremely poor.

The outbreak in 2014, occurred within the context of an ongoing humanitarian crisis
resulting in a total of 6,421 cases including 167 deaths (CFR 2.6%) being reported
from 16 counties in the five states of Central Equatorial, Eastern Equatoria, Western
Equatoria, Upper Nile and Jonglei. As of 4 October 2015, a total of 1,814 cholera
cases including 47 deaths (CFR= 2.59%) had been reported in three counties of South
Sudan, including Bor.

According to the 2012 community for development (C4D) KAP study, on average,
(68%) of the respondents from the ten states, used water and soap to wash their
hands. While almost a third of the population used either water only (27%) or water
and soil (2%)).

Globally adequate drinking water, sanitation, and hygiene are all essential ingredients
to ensure human health. The same is true for proper wastewater management, which
is a basic prerequisite for environmental health.

2
Improving upon these services will bring economic gains while also helping to build
resilience given increasing climate variability.

Many developing countries are already today struggling to cope with chronic water
shortages and the inadequacies of their existing water infrastructure. They are also
facing unprecedented population growth, rapid urbanization, and increased economic
activity. Basic needs remain unmet, and the human right to water and sanitation
remains unrealized for billions of people worldwide.

Against this background, global water security has risen on the international agenda.
In fact, in 2012, a US Intelligence Community Assessment identified water-related
problems in developing countries, such as increased risk of disease from unsafe
drinking water and poor sanitation, as a threat to American interests. Just last year, the
World Economic Forum identified water crises as the global systemic risk of third
highest concern. Policies, institutions, and infrastructure to improve drinking water
sanitation, hygiene and wastewater management must be put in place today. Such
actions will also build resilience to cope with the future impacts of climate change.

The world’s drinking water situation is improving. However, there is still cause for
concern. In 2012, it was reported that the international community had reached the
Millennium Development Goal (MDG) target, to halve the proportion of people
lacking access to safe drinking water, three years before the 2015 deadline. While this
is a welcome achievement, there is an important caveat.

The proxy indicator used to measure progress towards this target is “access to an
‘improved’ drinking water source.” This indicator has limited meaning since it does
not represent a reliable measure of drinking water safety. In fact, a recent study
commissioned by the World Health Organization (WHO) and UNICEF estimates that
at minimum 1.8 billion people around the globe use focally contaminated drinking
water. This is more than twice the official figure from the WHO/UNICEF Joint
Monitoring Programmed of 748 million lacking access to an improved drinking water
source.

3
The global sanitation problem requires urgent attention. The MDG sanitation target,
to halve the proportion of people lacking access to improved sanitation by 2015, is
seriously off-track. Today, 2.5 billion people still lack access to basic sanitation. In
many parts of sub-Saharan Africa, less than half of the population uses a toilet fit for
human beings. One billion people do not use a toilet at all. In South-East Asia almost
40% of the population defecates in the open. In cases where toilets exist, it is
important that they hygienically separate human excreta from human contact. But this
step by itself is not sufficient to protect health.

There are other key factors. For example, excreta are often captured in unlined latrine
pits from where excreta freely leach into the ground water. Also, when latrines are
emptied, the fecal sludge is frequently dumped into surrounding water bodies. Both
features cause major negative health impacts on communities and the environment at
large. Approximately ninety percent of wastewater in developing countries is
discharged directly into rivers, lakes, and seas. To realize sanitation’s health benefits,
the full sanitation chain, including wastewater management, must be considered.
Currently, there is no global monitoring to track progress in wastewater management.

Hygiene poses another global health challenge. However, thus far, hygiene has not
been prioritized on the international development agenda, even though hand washing
with soap could save 300,000 people annually. Safe drinking water and sanitation in
the absence of hygienic behavior will not prevent feco-oral infections. Many
households, for example, have no other option than to store water before use. Even if
the original source of the water is safe, the water is frequently contaminated by
unhygienic conditions and practices in the home.

Across the developing world, hand washing and menstrual hygiene facilities along
with toilets are often not available in schools, thereby deterring attendance,
particularly for adolescent girls. A recent study by Freeman et al., published in
the Journal of Epidemiology and Infection, estimates that inadequate hand hygiene
practices affect 80% of the global population. Even though hygiene’s health benefits
are well documented, there is no global development target or monitoring framework
to track the uptake of improved hygiene practices.

4
There are tremendous economic gains that can be realized with improved drinking
water, sanitation, and hygiene. The WHO estimates that for every US dollar invested
in improved drinking water and sanitation there is an economic return of four US
dollars resulting from health and productivity gains. It is estimated that the benefits of
achieving universal access to improved sanitation would outweigh costs at least five-
fold, and for improved drinking water at least two-fold, with a minimum combined
economic benefit of over 220 billion US Dollars annually.

The WHO estimates the total global economic loss per annum resulting from poor
water supply and sanitation at 260 billion US Dollars. Per World Bank studies,
countries in sub-Saharan Africa, as well as Bangladesh and India, on average lose
more than 4% and 6% of their Gross Domestic Product (GDP), respectively, due
to inadequate sanitation. The evidence is clear: poor sanitation and inadequate water
supply play a role in keeping countries poor.

The burden of water-related diseases curtails efforts to improve public health in the
developing world. Diarrhea – most often related to unsafe drinking water, poor
sanitation and inadequate hygiene – is one of the leading causes of death among
children under the age of five. It kills more children than Malaria or HIV/AIDS. The
WHO estimates that exposure to inadequate drinking water, sanitation and hand
hygiene was responsible for 58% of deaths from diarrhea, adding up to 840,000
deaths in low and middle-income countries, in 2012. This translates into 1.5% of the
global disease burden, even 5.5% for children under five.

There is growing evidence that repeated exposure to unsafe drinking water; poor
sanitation and inadequate hygiene have a significant impact on stunting. This comes
about because of intestinal worm infections, diarrheal diseases and environmental
enteropathy which lead to a poor nutritional status. Cholera is also transmitted via
contaminated water. The cholera epidemic in Haiti has killed more than 8,500
people since 2010.

5
Taking all the above into account, water, sanitation (including wastewater) and
hygiene must be given greater priority in the health community, which presently puts
too much focus on curative approaches.

In their paper “Hygiene, Sanitation and Water: Forgotten Foundations of Health,”

published in 2010, Bartram and Cairncross conclude that the “active involvement of
health professionals in hygiene, sanitation and water supply is crucial to accelerating
and consolidating progress for health”. To translate this recommendation into
practice, the WHO along with other key actors in the health sector, should streamline
drinking water, sanitation, and hygiene as preventative medicine. Through a push for
more funding allocation and better policy design, tangible health benefits could be
realized. And, most importantly, improvements will be made in the lives of billions of
people.

Adequate drinking water, sanitation, and hygiene are all essential ingredients to
ensure human health. The same is true for proper wastewater management, which is a
basic prerequisite for environmental health. Improving upon these services will bring
economic gains while also helping to build resilience given increasing climate
variability.

Many developing countries are already today struggling to cope with chronic water
shortages and the inadequacies of their existing water infrastructure. They are also
facing unprecedented population growth, rapid urbanization, and increased economic
activity. Basic needs remain unmet, and the human right to water and sanitation
remains unrealized for billions of people worldwide. Against this background, global
water security has risen on the international agenda. In fact, in 2012, a US Intelligence
Community Assessment identified water-related problems in developing countries,
such as increased risk of disease from unsafe drinking water and poor sanitation, as a
threat to American interests. Just last year, the World Economic Forum identified
water crises as the global systemic risk of third highest concern. Policies, institutions,
and infrastructure to improve drinking water sanitation, hygiene and wastewater
management must be put in place today. Such actions will also build resilience to
cope with the future impacts of climate change.

6
The world’s drinking water situation is improving. However, there is still cause for
concern. In 2012, it was reported that the international community had reached the
Millennium Development Goal (MDG) target, to halve the proportion of people
lacking access to safe drinking water, three years before the 2015 deadline. While this
is a welcome achievement, there is an important caveat. The proxy indicator used to
measure progress towards this target is “access to an ‘improved’ drinking water
source.” This indicator has limited meaning since it does not represent a reliable
measure of drinking water safety. In fact, a recent study commissioned by the World
Health Organization (WHO) and UNICEF estimates that at minimum 1.8 billion
people around the globe use focally contaminated drinking water. This is more than
twice the official figure from the WHO/UNICEF Joint Monitoring Programme of 748
million lacking access to an improved drinking water source.

The global sanitation problem requires urgent attention. The MDG sanitation target,
to halve the proportion of people lacking access to improved sanitation by 2015, is
seriously off-track. Today, 2.5 billion people still lack access to basic sanitation. In
many parts of sub-Saharan Africa, less than half of the population uses a toilet fit for
human beings. One billion people do not use a toilet at all. In South-East Asia almost
40% of the population defecates in the open. In cases where toilets exist, it is
important that they hygienically separate human excreta from human contact. But this
step by itself is not sufficient to protect health. There are other key factors. For
example, excreta are often captured in unlined latrine pits from where excreta freely
leach into the ground water. Also, when latrines are emptied, the fecal sludge is
frequently dumped into surrounding water bodies. Both features cause major negative
health impacts on communities and the environment at large. Approximately ninety
percent of wastewater in developing countries is discharged directly into rivers, lakes,
and seas. To realize sanitation’s health benefits, the full sanitation chain, including
wastewater management, must be considered. Currently, there is no global monitoring
to track progress in wastewater management.

Hygiene poses another global health challenge. However, thus far, hygiene has not
been prioritized on the international development agenda, even though hand washing
with soap could save 300,000 people annually. Safe drinking water and sanitation in
the absence of hygienic behavior will not prevent feco-oral infections. Many

7
households, for example, have no other option than to store water before use. Even if
the original source of the water is safe, the water is frequently contaminated by
unhygienic conditions and practices in the home. Across the developing world, hand
washing and menstrual hygiene facilities along with toilets are often not available in
schools, thereby deterring attendance, particularly for adolescent girls. A recent study
by Freeman et al., published in the Journal of Epidemiology and Infection, estimates
that inadequate hand hygiene practices affect 80% of the global population. Even
though hygiene’s health benefits are well documented, there is no global development
target or monitoring framework to track the uptake of improved hygiene practices.

There are tremendous economic gains that can be realized with improved drinking
water, sanitation, and hygiene. The WHO estimates that for every US dollar invested
in improved drinking water and sanitation there is an economic return of four US
dollars resulting from health and productivity gains. It is estimated that the benefits of
achieving universal access to improved sanitation would outweigh costs at least five-
fold, and for improved drinking water at least two-fold, with a minimum combined
economic benefit of over 220 billion US Dollars annually.

The WHO estimates the total global economic loss per annum resulting from poor
water supply and sanitation at 260 billion US Dollars. Per World Bank studies,
countries in sub-Saharan Africa, as well as Bangladesh and India, on average lose
more than 4% and 6% of their Gross Domestic Product (GDP), respectively, due
to inadequate sanitation. The evidence is clear: poor sanitation and inadequate water
supply play a role in keeping countries poor.

The burden of water-related diseases curtails efforts to improve public health in the
developing world. Diarrhea – most often related to unsafe drinking water, poor
sanitation and inadequate hygiene – is one of the leading causes of death among
children under the age of five. It kills more children than Malaria or HIV/AIDS. The
WHO estimates that exposure to inadequate drinking water, sanitation and hand
hygiene was responsible for 58% of deaths from diarrhea, adding up to 840,000
deaths in low and middle-income countries, in 2012. This translates into 1.5% of the
global disease burden, even 5.5% for children under five. There is growing evidence
that repeated exposure to unsafe drinking water; poor sanitation and inadequate
hygiene have a significant impact on stunting. This comes about because of intestinal
8
worm infections, diarrheal diseases and environmental enteropathy which lead to a
poor nutritional status. Cholera is also transmitted via contaminated water. The
cholera epidemic in Haiti has killed more than 8,500 people since 2010.

Taking all the above into account, water, sanitation (including wastewater) and
hygiene must be given greater priority in the health community, which presently puts
too much focus on curative approaches. In their paper “Hygiene, Sanitation and
Water: Forgotten Foundations of Health,” published in 2010, Bartram and Cairncross
conclude that the “active involvement of health professionals in hygiene, sanitation
and water supply is crucial to accelerating and consolidating progress for health”. To
translate this recommendation into practice, the WHO along with other key actors in
the health sector, should streamline drinking water, sanitation, and hygiene as
preventative medicine. Through a push for more funding allocation and better policy
design, tangible health benefits could be realized. And, most importantly,
improvements will be made in the lives of billions of people.

1.3 Profile of the Organization

The Catholic Relief Services/Resilience Food Security Program (RFSP) is funded by
United States agency for international development (USAID) Food for Peace (FFP)
and implemented by Catholic Relief Service (CRS) and Save the Children Federation
(SCF) in partnership with the government of Jonglei State, South Sudan. RFSP aims
to support communities in strengthening food security in nine counties (Bor, Twic
East, Duk, Uror, Ayod, Akobo, Nyirol, Pibor and Fagak) with a package of
interventions including resilience and recovery activities, provision of food assistance
(conditional and unconditional) and non-food items (NFIs), preventive nutrition and
WASH.

The program targets conflict affected and vulnerable households in the nine counties.
RFSP has carried out assessments and rehabilitation of boreholes and established and
trained water WPUCs and provided spare parts and rehabilitation tool kits for
borehole maintenance. RFSP also trained home hygiene promoters (HHPs) and school
WASH clubs. RFSP carried out hygiene promotion activities in the community
through awareness raising, house to house visits and community group discussions. In
schools RFSP carried out hygiene promotion activities through role plays, dramas,

9
poems, songs, school compound cleaning campaigns and quizzes and competitions.

Catholic Relief Services was founded in 1943 by the Catholic Bishops of the United
States to serve World War II survivors in Europe. Since then, it has expanded in size
to reach more than 130 million people in more than 100 countries on five continents.

For over 75 years, CRS mission has been to assist impoverished and disadvantaged
people overseas, working in the spirit of Catholic social teaching to promote the
sacredness of human life and the dignity of the human person. Although her mission
is rooted in the Catholic faith, its operations serve people based solely on need,
regardless of their race, religion, or ethnicity. Within the United States, CRS engages
Catholics to live their faith in solidarity with the poor and suffering people of the
world.

CRS is motivated by the example of Jesus Christ to ease suffering, provide

development assistance, and foster charity and justice. We are committed to a set of
guiding Principles and hold ourselves accountable to each other for them.
Watch what happens when little miracles touch the lives of the most vulnerable
people around the world. Witness the lifesaving help and hope provided by Catholic
Relief Services. Look at just how far your heart can reach.
Faith Action Results: We put our faith into action to help the world poorest create
lasting change.
Faith: Faith is our foundation. We have faith in the people we serve and our shared
ability to build a more just and peaceful world.
Action: The desire to serve is not enough. We must act collaboratively to bring about
real improvements in peoples’ quality of life and genuine engagement in building
peace and justice.
Results: Demonstrated through measurable outcomes, our actions must be effective in
alleviating human suffering, removing root causes and empowering people to achieve
their full potential.

2.3 Catholic Relief Vision, Mission and Core Values

The VISION of the CRS is to create a community of well-educated individuals who

will significantly enhance desired life outcomes for individuals with disabilities.

10
The MISSION of the CRS is to enhance the performance of
organizations, professionals, advocates, families, employers, and individuals with
disabilities, through education, organizational development, technical assistance, and
consultation. Our goal is to assist individuals with disabilities to achieve integrated
employment outcomes and independence.
The CRS Core values and how we believe they further prepare our athletes for on
field performance and contributions to the community.
Integrity. A student-athlete with integrity always strives to do what is right in the face
of adversity
Respect.
Accountability.
USAID Food for Peace (FFP) funded two programs’ Pathways to Resilience
Recovery P2R for food security, recovery, and Resilience program 2020 -2022.
Directly implemented by consortium of CRS and Save the Children in Greater
Jonglei.
Strong partnerships with Government technical ministries and RRC.
Sector activities at Payam and Boma level in disaster risk reduction (DRR), farming,
livestock and fisheries, value chain, savings and market access, WASH, and nutrition.
Address the underlying trauma that fuels recurring violence and conflict.

1.3 Statement of the Problem

In South Sudan, there is inadequate access of safe sanitation and hygiene and as such,
13 percent of the population has access to adequate sanitation facilities which is not
enough. For those using an improved water source, 34 percent travel less than 30
minutes to and from the source while the remaining travel more than 30 minutes.

This laborious daily task of collecting water is overwhelmingly completed by women.

Adult women are most commonly the water carriers (85.6%) but female children
under age 15 are also significant collectors (8.8%).

Beyond limited access to improved water and sanitation there is low knowledge and
practice of good hygiene behaviors. The lack of access to improved water and
sanitation and poor hygiene behaviors is a principal cause of water-related diseases
such as diarrhea and cholera, infection from guinea worm, and contributes to

11
malnutrition. Water, sanitation, and hygiene (WASH) is also associated with
educational access and nutritional outcomes.

Access to water and sanitation can be the reason why girls are kept out of school and
improved access to water and sanitation at schools has been shown to increase school
attendance among girls. Access to improved drinking water sources and improved
sanitation and hygiene can improve nutritional outcomes and can prevent intestinal
parasitic infections alongside diarrhea, and these infections also have synergistic
effects with increasing incidences of malnutrition.

Improved access to safe water, sanitation, and adequate hygiene can predict child
growth and malnutrition and is associated with improved child development
outcomes. Improving WASH is necessary to improve health, nutrition, and
educational outcomes in South Sudan. Beyond these burdens related to poor WASH
access and behaviors, it is also associated with economic losses, environmental
impacts, gender/social burdens, and potential conflict. Access to and good
management of water resources improves health and education outcomes, brings
more certainty and efficiency in productivity across economic sectors, and contributes
to the health of the ecosystem
Access to improved water and sanitation facilities does not, on its own, necessarily
lead to improved health. There is now very clear evidence showing the importance of
hygienic behavior, in particular handwashing with soap at critical times: after
defecating and before eating or preparing food. Handwashing with soap can
significantly reduce the incidence of diarrhea, which is the second leading cause of
death amongst children under five years old. In fact, recent studies suggest that
regular handwashing with soap at critical times can reduce the number of diarrhea
bouts by almost 50 per cent.

Good hand-washing practices have also been shown to reduce the incidence of other
diseases, notably pneumonia, trachoma, scabies, skin and eye infections and diarrhea-
related diseases like cholera and dysentery. The promotion of handwashing with soap
is also a key strategy for controlling the spread of Avian Influenza (bird flu).

The key to increasing the practice of handwashing with soap is to promote behavioral
change through motivation, information, and education. There are a variety of ways to

12
do these including high-profile national media campaigns, peer-to-peer education
techniques, hygiene lessons for children in schools and the encouragement of children
to demonstrate good hygiene to their families and communities. See the hygiene
promotion page [link: Hygiene promotion page] for more information.

It is also true that without water there is no hygiene. Research shows that the less
readily available water is, the less likely that good hygiene will be practiced in
households.

‘’Therefore, there is a need to improve and expanded access to water, hygiene and
sanitation services at household level in rural communities”

1.4 Objectives of the Study

1.4.1 General Objective

The main objective of the study is to assess the current coverage (access and
availability) of safe drinking water, sanitation facilities, hygiene practices, knowledge
and attitudes related to WASH within the targeted communities.
‘’A case study of Catholic Relief Services ‘’
1.4.2 Specific Objectives
(i) To assess the current access and availability of safe water sources, sanitation
facilities and hygiene practices within the conflict affected communities.
(ii) To assess the current KAP of the targeted communities and baseline WASH
indicators tracked by RFSP.

(iii) To explore alternative delivery interventions for WASH programming that

could result in better outcomes.

1.5 Research Questions

(i) What is the current community access to water sanitation facilities and
hygiene practices and how does this compare to set standards?

(ii) Are there seasonal variations on sources of water?

(iii) Are communities employing any water purification methods? If yes, which
ones?

13
 (iv) What is the current knowledge of water, sanitation and hygiene in
communities and how is this evident from their attitude and practices?

(v) What is the incidence of diarrheal diseases within the target communities?

(vi) What can be done to improve the current WASH situation and who are the
key players to be co-opted into this?

1.6 Significance of the Study

1.6.1 Catholic Relief-RFSP beneficiaries

The Resilience Food Security RFSP beneficiaries will be likely to benefit from this
study by gaining insights concerning the relationship between importance of Water
Sanitation & Hygiene and the factors influencing it.

1.6.2 Researchers
Researchers who are doing related study will use this research as their secondary data.
The research will also propose other areas which the researcher can explore further.
They can also do another research in the same way to weight the trend.

1.7 Limitation of the Study

1.7.1 Confidentiality
Confidentiality was a major point of concern as some respondent reluctant in giving
details to someone as they consider as a stranger, thinking that the researcher would
use the information to their competitive advantage. The researcher overcome this
challenge by producing a letter of introduction which was attached to the
questionnaires. This assured them the purpose of the study and that the information
they give shall be considered confidential.

14
1.7.2 Uncooperative Respondents
The study will be encountered poor cooperation from respondents. Moreover, the
respondent will restrict themselves to the responsibilities and duties. This will lead
the researcher to be ignored when enquiring and acquiring relevant information,
however, the researcher will inform the respondents on the importance of the study
and cited the top beneficiaries.

1.8 Scope of the study

The study was carried out at Catholic Relief Services which is in Jonglei State of Bor
County. The main aim was to assess the current coverage (access and availability) of
safe drinking water, sanitation facilities, hygiene practices, knowledge and attitudes
related to WASH within the targeted communities. The departments under study
included top management, middle and support staff management from administration
department. The study was undertaken within a period of three months of June, July
and August 2021.

15
 CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
The review is an important part of the objective approach to research in all fields of
enquiry. This is aimed at identifying the research gaps to the existing literature and
emphasizing on the need to carry out this study which is concerned with examining
the current coverage (access and availability) of safe drinking water, sanitation
facilities, hygiene practice, knowledge and attitude related to WASH within the
targeted communities.
The purpose of this literature review is to provide the researcher with means of
getting to the frontiers of knowledge of the issue under investigation. To this end, the
present chapter covers a review of theoretical literature review of analytical literature
of analysis and gaps to be filled, a summary of the chapter and the conceptual
framework.
2.2 Review of theoretical literature-Water supply, sanitation, and hygiene
(WASH) and the MDG’s
Estimates from the WHO and UNICEF show that about 1.1 billion people lack access
to improved water supplies and 2.6 billion people lack adequate sanitation worldwide
(Gopal et. al. 2009). Goal 7, Target 7 C of the MDG’s directly refers to drinking water
and sanitation and aims to reduce by half the proportion of people without these
amenities (O'Hara, Hannan and Genina 2008; United Nations 2010).
2.2.1 Water supply
A safe water supply has been defined as a source which is likely to supply water
which is not detrimental to health (Hamner et. al., 2006). Safe water sources include:
a household piped water connection; a public standpipe; a borehole; a protected dug
well; a protected spring and a rainwater collection system (WHO/UNICEF 2000;
Cairncross and Valdmanis 2006). If these sources can provide 20 litres per capita per
day at a distance which is no greater than one kilometer from the user’s dwelling, then
they are improved sources (Hamner et. al, 2006; O'Hara, Hannan and Genina 2008).
Cairncross and Valdmanis (2006) refer to these as reasonable sources, which are
usually house connections and public facilities. However, according to the Global
Water Supply and Sanitation Assessment 2000 Report, some countries have used
more stringent definitions of an improved water source than others (WHO/UNICEF
2000). Unimproved water sources are identified as: unprotected wells and springs,
16
vendors and tanker-trucks, and bottled water (WHO/UNICEF 2000). Cairncross and
Valdmanis (2006) note that what one group of consumers may consider to be a
perfectly satisfactory water supply system may be unsatisfactory for another group, as
this may depend on social and cultural differences between groups. They further state
that “water supply is not a single, well-defined intervention… but can be provided at
varying levels of service with varying benefits and differing costs” (Cairncross and
Valdmanis 2006, 771).
Most of the benefits conferred by water supply revolve around access to water in
quantity, and this can be based on the technology used to supply it (Cairncross and
Valdmanis, 2006). However, from the literature reviewed it seems that more attention
is placed on the technology (for example household connections) with the assumption
that the appropriate quantity will follow.
Cashman, Nurse and Charlery (2010) note that the definitions used for gauging MDG
goal 7, target 7C, do not say enough regarding reliability and adequacy of potable
water supply or sanitation. They also point out that not all individuals who have
access may be able to use these facilities for various reasons such as aging
infrastructure and increasing water demands by urbanization and tourism. Problems
resulting from hurricanes and droughts which result in damaged infrastructure and
intermittency also have implications for the reliability and adequacy of supply.

Reservations about what is meant by the term “improved water source” have been
acknowledged internationally (WHO/UNICEF 2000), due to arguments that it is too
focused on the distance to the source and the quantity supplied. This is important
because an ample water source which is nearby does not necessarily guarantee access.
It is also worth noting that increased water access does not guarantee increased water
use, therefore other factors must come into play (Fewtrell and Colford 2004). These
other factors include cost (affordability by users) and the reliability of supply.
Cairncross and Valdmanis (2006) have indicated that if a water supply is improved it
would provide water of a better quality, convenience, and reliability than traditional
sources classified as not improved. Convenience would include regularity of supply,
cost, and the number of users per source.
Reports have indicated that although statistics may show high percentages of
improved water sources, sometimes this does not reflect the situation on the ground
(O'Hara, Hannan and Genina, 2008). According to WHO/UNICEF (2000), in terms of

17
water supply and sanitation, national consolidated data may not be representative of
the poorest and most vulnerable individuals because they are usually hidden in the
national totals and averages.
Clasen and Cairncross (2004) have pointed out that in terms of potable water quality a
greater focus needs to be placed on point of use treatment. Fewtrell and Colford
(2004) also point out that there has been a tendency to focus on the provision of
household connections which does not include household water storage. This
therefore brings to the fore the issue of household water management as a means of
addressing potential water and sanitation related health issues.
Nath (2003) agrees that although public health concerns are usually raised in the
institutional setting, there is a tendency to not acknowledge the home as a setting of
equal importance. It was further reported that improving health status requires an
improvement in attitude concerning hygiene in the home and health education, both in
tandem with community water supply and environmental sanitation programs.
A study conducted by Eshcol, Mahapatra and Keshapagu (2009) in India showed that
faecal contamination of treated pipe borne water after collection was associated with
water handling and hygiene practices in urban slums. They noted that the water was
supplied on alternate days (intermittently), hence necessitating up to 48 hours of
storage in households before subsequent supply. This resulted in dramatic increases in
contamination after collection; hence it was acknowledged that until the problem of
intermittent supply is resolved, the biggest impact to health must be made at the
household level. As a coping strategy various household practices could be done to
limit the contamination of stored water before drinking. These include collecting
water in ways which limit its contamination; storing water properly (for example
completely covering containers); and treating stored water before drinking.
2.2.2 Sanitation
Cairncross and Valdmanis (2006) acknowledged that sanitation refers to excreta
disposal but also includes other environmental health interventions. The term
sanitation therefore also loosely falls under the broader definition of environmental
sanitation, which refers to arrangements which cover issues related to drainage of
stormwater and effluents, flood management, collection and, disposal of garbage and
removal of human excreta (Pandve 2008; Rautanen 2010). Pandve (2008) further
highlights that environmental sanitation involves not only the facilities which are
provided by governmental authorities but also includes the attitude of the community.
18
This is since a better environment can result if community members work towards the
same goal.

In the context of goal 7, target 7C of the MDG’s; it seems that sanitation is seen
principally as the removal of human excreta or the availability of appropriate facilities
for its disposal. For example, in tracking progress of the MDG’s the term improved
sanitation is used, and it refers to connection of households to a private or sewer
septic system (with a soak away), a pour flush latrine, a simple pit latrine, or a
ventilated improved pit latrine (Hamner et. al. 2006: WHO/UNICEF 2000). All
sanitation technologies are deemed adequate as long they are private or shared but not
public and provided that the hygienic separation of human excreta from human
contact exists. Although they may be private, bucket latrines and latrines with open
slab-less pits are deemed unimproved (Cairncross and Valdmanis 2006).

Public latrines fail to provide an adequate solution to the community excreta disposal
needs because of problems with inadequacies in their maintenance and inaccessibility
at night by the elderly, disabled and young children. It should be noted that these
inadequacies sometimes lead to open defecation or inappropriate excreta disposal
which sometimes reach sensitive aqueous environments or pose risks of human
contact (Cairncross and Valdmanis 2006; WHO/UNICEF 2000). This therefore means
that just having these public latrines constructed is not a clear-cut solution to
resolving sanitation problems.

The ability to engage in good sanitation depends on the availability of water which is
used for cleaning and elimination of wastes. Water availability therefore influences
the type and functionality of the sanitation facilities which exist (Pandve 2008) and as
such it is not unusual for the two to be studied in relation to each other.

There have been differences in opinion as to the combined effect of water and
sanitation services on users. According to Esrey et. al. (1991), from the public health
standpoint (as it relates to diarrhoeal disease), the combined effect of water and
sanitation is no greater than either component separately. However, Cairncross and
Valdmanis (2006) have considered the effects to be both independent and additive.

In the Caribbean it has been reported that rural sanitation gets much less attention and
financial support than urban sanitation. It has also been reported that generally, only a

19
small fraction of industrial and municipal wastewater is treated before being disposed
into terrestrial and aquatic environments (Vassell 2009; Smith 2008).

Smith (2008) noted that the critical aspects of sanitation which have been identified in
the Caribbean are as follows: interagency and inter-ministerial cooperation;
behavioural change (cultural norms and practices); development of community
sanitation programs; development of school sanitation programs; development of
micro-financing enterprises and the introduction of regional and local technologies.
Smith (2008) further mentioned that the absence of central

Collection/treatment systems in high water table areas and the improper disposal of
garbage/plastic bottles were problems.

2.2.3 Hygiene

In terms of hygiene, it may refer to a practice which is either personal or domestic.

Personal hygiene refers to the use of water for cleaning parts of the body and
domestic hygiene refers to water used to clean items in the home such as food,
utensils, and floors (Esrey et. al. 1991). In many articles reviewed, hygiene practice
was usually considered as part of water and sanitation research. This is because all
three components (water, sanitation, and hygiene) commonly impact human health.
These components also influence each other, for example, poor hygiene has been
shown to be a result of low water availability and inconvenient water supply (such as
low pressure, intermittence and crowding) (Karn and Harada 2002; Prüss-Üstün et. al.
2004).

Poor hygiene would also be expected to have sanitary consequences. As such, WHO
and UNICEF have considered hygiene information as an important component of
their work on water and sanitation issues (WHO/UNICEF 2000). In terms of the
combined importance of all three components: water supply, sanitation, and hygiene
promotion on the reduction of diarrhoea disease have been regarded as both
independent and additive to one another (Cairncross and Valdmanis 2006).

Interventions which promote hand washing with soap as a single personal hygiene
practice have been shown to be most effective when compared to other behaviours
(Cairncross and Valdmanis 2006). Kawata (1978) also notes that the belief that water

20
availability for personal hygiene is of prime importance for diarrhoea control is not
uniform among researchers. Other important factors such as wastewater disposal,
solid waste management and human settlement issues have been shown to have
implications on health (Nath 2003; Kawata 1978).

A literature review on water, sanitation, and hygiene by Fewtrell and Colford (2004)
found that, generally hygiene interventions which comprise handwashing and hygiene
education in childcare centres significantly contribute to a reduction in diarrhoeal
disease. Metwally et. al. (2007) stressed that public access to appropriate information
to increase awareness and changes in hygiene patterns are important to public health.
They further claimed that the result would lead to a greater tendency of the public to
protect themselves from infectious diseases.

Tumwine et. al. (2002) highlighted hygiene practices as a key compliment to

improved water and sanitation programs. They warned that if the hygiene component
was not included, some of the environmental health benefits would be lost.

It can also be said that the adequacy of water is a necessary condition to good
hygiene. This is because when there is poor sanitation, supplying enough water per
capita enables residents to practice good hygiene. This in turn safeguards public
health by enabling residents to protect themselves from sanitation related diseases.
2.2.4 Disease types and transmission routes
Waterborne diseases are primarily caused by human and animal faecal contamination
(San Martin 2002; Eshcol, Mahapatra and Keshapagu 2009). However, these
infections are usually of human origin and to a lesser extent caused by animals (Prüss-
Üstün et. al. 2004). Since safe water can become contaminated with faecal matter
during collection, transport, and storage (Clasen and Cairncross 2004), it is important
to devise ways of limiting contamination on these levels.

Water is an ideal medium for the transmission of diseases from faecal origin. Humans
interact with water in different ways and as such sanitation-based diseases may be
transmitted through various routes. According to Clasen and Cairncross (2004) these
routes have been classified by White, Bradley and White (1972) as shown below

21
Table 2.1. The classification of water related diseases according to White,
Bradley, and White (1972)
Transmission Description Disease group Example
route
Waterborne The pathogen is in water that is Faecal-oral Diarrhoea,
ingested dysenteries,
typhoid fever
Water-washed Transmission by insects that Skin and eye Scabies,
(or water breed in water or bite near water infections trachoma
scarce) Transmission via aquatic Water-based Schistosomiasis,
Water- Based
intermediate host (for example a guinea worm
Water-related Transmission
snail) by insects that Water related- Dengue, malaria,
insect vector breed in water or bite near water insect vector trypanosomiasis

Source: Cairncross and Valdmanis (2006)

Cairncross and Valdmanis (2006), reported that most diarrhoeal diseases are
transmitted through water-washed and not waterborne routes (although the most
notable epidemics such as cholera and typhoid are waterborne), hence the
significance of the hygiene component of WASH interventions.
In terms of the faecal-oral disease group, it should be noted that water is the ideal but
not the only medium which facilitates the faecal-oral pathway (Orlando 2001). Prüss-
Üstün et. al. (2004), note that the predominant pathway of infection will depend on
the survival characteristics of the pathogen, the local infrastructure in place and
human behaviour.

There are five main media by which faecal-oral diseases are transmitted. This is
usually represented in a schematic known as the F-diagram. This diagram has been
widely used as a model for the transmission of faecal-oral diseases (Bostoen, Kolsky
and Hunt 2007). The F-diagram as represented by Prüss-Üstün et. al. (2004) shows
the connection between the faecal pathogen sources, the environment and the
individual as seen below:

22
Figure 2.1 Modified F-diagram showing transmission pathways of faecal-oral
disease.

Source: Prüss-Üstün et. al. (2004)

23
2.2.5 Socioeconomic aspects
In developing countries, the consequences of poor sanitation are often greatest felt
among poor residents of densely settled areas (Orlando 2001). Nath (2003) has noted
that inadequate housing usually leads to poor home hygiene in poor urban areas.
In terms of WASH and health, it has been reported that the prevalence and intensity of
helminth infections are influenced by certain occupations, household clustering,
poverty, and behaviours (Hotez et. al. 2006). According to Keusch et. al. (2006), a
strong relationship exists between poverty, unhygienic environments, and the severity
of diarrhoeal episodes, especially in children less than five years of age.
Cashman, Nurse and Charlery (2010) have noted that in the Caribbean region, there
has been significant progress in extending water coverage and sanitation service,
however challenges such as maintaining access, coverage and quality standards still
exist. These challenges have been increased by factors such as population pressures,
urbanization, economic development, and the growth in tourism.
Some researchers have also concluded that the installation of water supplies and
latrines should be done in parallel with improvements in housing and socio-economic
status to have a marked effect on infant health (Kawata 1978). Orlando (2001) also
indicated that with the implementation of sanitation projects and solutions, the factors
of social change need to be considered to ensure success; hence this change should
provide technologies which must be supported by the target residents.

San Martin (2002) noted that proper water resources management provides significant
social effects which can be grouped into three categories namely: health, poverty
alleviation and the reduction of vulnerability to natural hazards. It was also
highlighted that water resources management infrastructure has several positive
impacts on the poor, notably its effect on promoting economic growth. Hence, there is
a corresponding poverty alleviation effect with any meaningful contribution to water
and sanitation infrastructure.

A study by Soares et al. (2002), who investigated the inequalities in access and use of
drinking water services in the Latin-American and Caribbean region, showed that the
factors which determine these inequalities are related to poverty. These inequalities
were reported to be directly related to family expenditures for drinking water supply
services. Therefore, families with a higher per capita expenditure were much more

24
likely to have a household water connection. They also recommended that periodic
surveys should be conducted to monitor the progress towards reducing these
inequalities.

A study on water and sanitation investments in the Caribbean conducted by Martin

and Sohail (2005) noted that water supply and sanitation infrastructural investments is
very capital intensive and governments bear a significant amount of these costs. They
noted that, attracting private investments is also a challenge because the payback of
water supply and sanitation projects could take as long as 20 to 30 years. 2.3 Climate
change and extreme weather events

In terms of climate change, the Caribbean which consists of small island developing
states (SIDS) is highly vulnerable. Many Caribbean islands are prone to frequent
damage due to their location in the hurricane belt. Natural disasters contribute to the
scale and magnitude of poor water and sanitation problems in the Caribbean which
usually involves infrastructural damage (destruction of toilets and water pipelines)
(Vassell 2009).

The preparedness for these events is not only necessary for protecting human lives
and property but for sustained economic growth and social development (San Martin
2002). It has been shown that damages from a single hurricane event can set back the
socioeconomic development of a country by at least 10 years (Trotz 2008). It is also
expected that climate change will have a profound effect on the socio-economic
development of Caribbean islands in the long term. The impacts of climate change
may even jeopardize the achievement of the MDG’s (Farrell, Nurse and Moseley
2007).

Cashman, Nurse and Charlery (2010), noted that increasingly there is the realization
that the degree of water availability will be vulnerable to extreme climate events. It is
expected that atmospheric warming, longer seasonal dry periods, and increased
drought frequencies will occur. This is therefore projected to have implications for
water resources availability. San Martin (2002) however notes that in comparison to
floods, the region is less often affected by droughts. The impact of droughts will
depend on the level of preparedness in facing these types of events.

25
Climate change may also lead to more intense rainstorms which in turn results in
increased run-off which then leads to increased flooding (Farrell, Nurse and Moseley
2007). High precipitation, flooding and hurricanes have resulted in sanitation
problems in some rural Jamaican communities. These problems included toilets
which were flooded and blown away, hence directly releasing faecal matter into the
environment and rivers (Vassell 2009). There is therefore a need to supply
communities with robust sanitation systems which can withstand the impacts of
natural disasters (Harvey and Reed 2005).
San Martin (2002) further notes that increased public awareness and improved
preparedness for floods and droughts are water resource management challenges in
the region. In terms of the impact of climate change on water resources in the
Caribbean and getting people to understand the value of water resources, Farrell,
Nurse and Moseley (2007, 8) noted that: “no policy, however well-intentioned and
conceived, will achieve the desired outcome if stakeholder education is not an
institutionalized element of the implementation process. This may require strategies
aimed at effecting behavioural and attitudinal change, dispelling false notion, and
enhancing public awareness.”
2.2.6 Gender
Men and women usually have different socially defined roles and responsibility in the
home and community. Cairncross and Valdmanis (2006) noted that there exists a
string of gender differences related to water supply and sanitation, in terms of their
perception of the social benefits. They indicated that in some studies male household
heads generally perceive the issue of improved sanitation as an improvement in social
status. Women however place more importance on issues of security, convenience,
aesthetics, and the tendency to be sexually harassed when sharing public facilities.
Vassell (2009) noted in a Jamaican study that both men and women were concerned
about water management although for different reasons.
The concerns of women were related to water management and efficiency of use in
the home because they were main water carriers. In some instances, men were more
concerned about water availability for washing motorbikes and cars.
Vassell (2009) further noted that water and sanitation challenges place a burden on
women in relation to their productive and community management roles. On the
community level, economic barriers can be created when drinking water is not
available. It was shown in the Jamaican study that because of the lack of sufficient
26
water supply, women were unable to translate ideas for food related businesses (such
as jam and jelly production) into practical projects. Other water intensive activities for
generating income such as hairdressing were also restricted.
2.2.7 Environmental implications
Some conditions which are potential indicators of high faecal-oral pathogen loads in a
community are: low sanitation coverage, faecal contaminated drinking water supplies,
irregular refuse collection and poor hygiene practices (Prüss-Üstün et. al. 2004).
Coastal pollution due to microbiological contamination is an important issue,
especially when considering that most of the world’s population (Griffin et. al. 2003)
have settled in these areas.

A review conducted by Griffin et al. (2003) noted that human and ecosystem health
are negatively impacted by a decrease in coastal marine water quality. They identified
the faecal-oral route as the means of transmission of all pathogenic viruses which
pose a public health threat in the near-shore marine environment.

Factors which increase coastal pollution from inland sources include the direct or
indirect disposal of wastewater into coastal waters (Griffin et. al. 2003). This is
exacerbated by the density of on-site septic tanks and high precipitation. San Martin
(2002) notes that when sanitation infrastructure or wastewater treatment facilities are
lacking or not functioning, the quality of coastal waters can be affected, and this has
implications for tourism dependent Caribbean islands and communities. As a result,
polluted coastal waters may pose health risks to tourists and residents alike, hence
having implications for the tourism industry.

2.2.8 Health
More attention should be given to the assessment of nutrition practices when
assessing the impact of WASH on the health of school children. We also don’t know
enough about the long-term impact of WASH interventions on child health. These are
some of the conclusions that researchers from the Center for Global Health and
Development at the University of Nebraska Medical Center (UNMC) drew from a
review of the literature. Dr. Ashish Joshi and research assistant Chioma
Amadi reviewed the impact of water treatment, hygiene, and sanitary interventions on
improving child health outcomes such as absenteeism, infections, knowledge,
attitudes, and practices and adoption of point-of-use water treatment. For their final

27
analysis they selected 15 peer-reviewed English-language studies published between
2009 and 2012 that focused on the effects of access to safe water, hand washing
facilities, and hygiene education among school-age children.

Eleven of the reviewed were conducted in developing countries and eight were rural
based. The child’s age, gender, grade level, socioeconomic index, access to hygiene
and sanitary facilities, and prior knowledge of hygiene practices were significantly
associated with the outcomes. Nutrition practices which are key factors associated
with the outcomes were rarely assessed.
Health is the level of functional and metabolic efficiency of a living organism. In
humans it is the ability of individuals or communities to adapt and self-manage when
facing physical, mental, or social changes.
As defined by World Health Organization (WHO), it is a "State of complete physical,
mental, and social well being, and not merely the absence of disease or infirmity."

The Constitution of the World Health Organization, which came into force on April 7,
1948, defined health “as a state of complete physical, mental and social well-being.”
The writers of the Constitution were clearly aware of the tendency of seeing health as
a state dependent on the presence or absence of diseases: so, they added to that
definition that an individual, if he is to be considered healthy, should not suffer from
any disease (…. “and not merely the absence of disease or infirmity”). In that way, the
definition of the World Health Organization simply added a requirement to the
previous position that allowed to declare someone healthy if no disease could be
found: the step forward that could have been taken in the conceptualization of health
as a dimension of existence which can co-exist with the presence of a disease or
impairment was thus not taken.

Today, three types of definition of health seem to be possible and are used. The first is
that health is the absence of any disease or impairment. The second is that health is a
state that allows the individual to adequately cope with all demands of daily life (also
implying the absence of disease and impairment). The third definition states that
health is a state of balance, an equilibrium that an individual has established within
himself and between himself and his social and physical environment.

28
The consequences of adopting one or another of these definitions are considerable. If
health is defined as the absence of disease, the medical profession is the one that can
declare an individual healthy. With the progress of medicine, individuals who are
declared healthy today may be found to be diseased tomorrow because more advanced
methods of investigations might find signs of a disease that was not diagnosable
earlier. How an individual feels about his or her state is not relevant in this paradigm
of health. How the surrounding people judge the behavior and appearance of an
individual is only relevant if their observations are congruent with the criteria of
abnormality that the medical profession has produced. The measurement of the state
of health of a population is also simple and will involve no more than counting the
individuals who, on examination, show defined signs of illness and comparing their
numbers with those who do not.

There are obvious difficulties with the first and the second of the definitions
mentioned above and with their consequences. There are individuals who have
abnormalities that can be counted as symptoms of a disease but do not feel ill. There
are others whose body tissues do not demonstrate changes but who feel ill and do not
function well. There are people who hear voices and might therefore be candidates for
psychiatric examination and possibly treatment – but live well in their community and
do not ask for nor receive medical care. There is a significant number of people who
have peptic ulcers and other diseases, experience no problems, do not know that they
have a disease and do not seek treatment for it. Some of these individuals will also
escape the second type of definition of health because they function as well as
expected in their age and gender group of the general population.

The third definition mentioned above makes health depend on whether a person has
established a state of balance within oneself and with the environment. This means
that those with a disease or impairment will be considered as being healthy to a level
defined by their ability to establish an internal equilibrium that makes them get the
most they can from their life despite the presence of the disease. Health would thus be
a dimension of human existence that remains in existence regardless of the presence
of diseases, somewhat like the sky that remains in place even when covered with
clouds. The advantage of this definition is that diseases do not replace individuals’
health: they may affect their balance severely but, at all times, the patients who suffer
from a disease (and their doctors) remain aware of the need to work simultaneously

29
on two tasks – one, to remove or alleviate the disease and the second to establish a
state of balance, as best they can, within oneself and in relation with their
environment. In fighting stigmatization that accompanies many chronic and some
acute diseases – such as mental disorders or leprosy – this definition is also useful
because it makes us speak and think about our patients as people who are defined by
different dimensions (including health) and who, at a point, suffer from a disease –
and thus make us say “a person with schizophrenia” rather than “a schizophrenic,” or
a ”person who has diabetes” rather than a “diabetic” and a “person with leprosy”
rather than a “leper.”

There is another important consequence of working with this definition of health. To

establish whether someone is in good health in accordance with this definition, the
doctor must explore how individuals who have a disease feel about it, how the disease
influences their lives, how they propose to fight their disease or live with it.
Laboratory findings and the presence of symptoms are thus important and necessary
ingredients in thinking about the state of health and the presence of a disease but are
not sufficient to reach a decision about someone’s health: it is necessary to view the
disease in the context of the person who has it to make a judgment about his or her
level of health. There is little doubt about the fact that going about the treatment of
diseases in this way would improve the practice of medicine and make it a more
realistic as well as a more humane endeavor.

The promotion of health is also affected by the differences in the definition of health.
The simplest definition of health – equated with the absence of disease – would lead
to a definition of the promotion of health as an effort to remove diseases and diminish
the numbers of individuals who suffer from them. The involvement of functioning in
the definition of health would be reflected in defining the promotion of health as a
process by which the capacity of individuals to cope will be enhanced and
strengthened, for example by regular and obligatory physical exercise. Both
definitions would lead to recommendations to improve the treatment of diseases, and
to remove risks factors that might lead to them – such as sedentary lifestyle, smoking,
bad eating habits and insufficient application of hygienic measures such as washing
one’s hands before meals.

30
The third definition of health, by its very nature, could not stop at efforts to remove
diseases and to diminish risk factors that might lead to disease. It would have to
involve the individuals whose health is to be promoted in an active way: it would
have to address the scales of values of individuals and communities to ensure that
health is placed higher on those scales. High value placed on health (not only on the
absence of disease) would make people undertake whatever is necessary to enhance
health: participating in preventive action and seeking treatment would become a
normal expression of the need to behave in harmony with one’s own and one’s
community values. Changing the place of health on the scale of values, however, is
not possible if left to the health sector alone: values are shaped throughout life under
the influence of parents, friends, and schools, the media, laws, and one’s own life
course and experience. Thus, changing values – for example to give health a higher
value, to promote health – must be a task for all of those involved in shaping values
and placing them on a scale rather than for the health system alone.

The huge challenges that face societies aiming to improve the health of their citizens
will not be appropriately answered if we do not change the paradigms of health and
disease and design strategies for future work using these new paradigms. Their
formulation and acceptance are a task that is before all of us and is urgent.

Example of How Important WASH is to Health in the Society.

Several assessments exist for collecting data on WASH in health care facilities. This
section describes those assessments and the data which were used to derive global
estimates. In general, there is a lack of publicly available data, and the data that do
exist do not use consistent indicators for WASH, making it difficult to compare data
from different sources. Assessments that include information on WASH in health care
facilities were identified after screening peer reviewed and grey literature from 18
information repositories. These information repositories are largely donor driven
initiatives or are coordinated by UN agencies, including the World Health
Organization. For purposes of this report, health care facilities include hospitals,
health centres, clinics and dental surgery centres and are generally places where
people receive health care from a trained professional. They include public, private,
and not-for-profit facilities (WHO, 2008). There is a large range in the size of health
care facilities, the services offered and provision of water and sanitation both in

31
facilities and within specific treatment areas (e.g., delivery rooms). In total, 90 health
care facility assessments that were conducted in 54 countries between 1998 and 2014
were identified. To derive coverage estimates, only one assessment was selected for
each country to prevent double or triple counting. Most of the assessments were
conducted in Africa (n=23) and the Americas (n=14), while information for other
regions was very limited. In the assessments identified, water access was more
frequently measured and reported than access to sanitation or hygiene. Furthermore,
only 20 of the assessments were reported to be nationally representative. Further
details on the methods employed for selecting and compiling datasets and for
calculating coverage estimates are included in Annex A. 2.1 SURVEY AND
CENSUSES Surveys, supported by international organizations, were the main source
of data. The three most common health care facility surveys are the Service
Availability and Readiness Assessment (SARA), the Service Delivery Indicator
survey (SDI) and the Service Provision Assessment (SPA). These surveys have
closely aligned methods and collect nationally representative data for a given country.
They are designed to be conducted periodically and sample from a master list of all
public and private health care facilities. Further information on those surveys is
summarized.Other assessments included one-time project evaluations or censuses,
focusing on specific services and settings, such as HIV/AIDS, child health and
emergencies. These censuses included WASH as a component of larger aims.
However, these censuses, compared to SDI, SARA and SPA, constitute a small
proportion of all facilities assessed and data used in this review. Health Management
Information Systems (HMIS) were explored as another possible source of data. HMIS
are routine reporting systems developed and managed by national governments to
collect a range of health-related indicators (e.g., diseases diagnosed and treated, or
number of beds available per hospital) (WHO, 2010). Unlike surveys, in which data
are collected by independent teams of enumerators, HMIS rely on self-reporting from
health care staff. However, of the 68 national HMIS surveys included in the WHO
Health Metrics network, none of the data sets or reports included WASH in health
care facility indicators1. Therefore, HMIS was not a source for this review.

32
2.2. 9 Environment

Environment is what is around something. It can be living or non-living things. It

includes physical, chemical and other natural forces. Living things live in their
environment. They constantly interact with it and change in response to conditions in
their environment. In the environment there are interactions between plants, animals,
soil, water, and other living and non-living things.

The word 'environment' is used to talk about many things. People in different fields of
knowledge (like history, geography or biology) use the word environment differently.
Electromagnetic environment is radio waves and other electromagnetic
radiation and magnetic fields. The galactic environment refers to conditions between
the stars.

In psychology and medicine a person's environment is the people, physical things,

places, and events that the person lives with. The environment affects the growth and
development of the person. It affects the person's behavior. It affects the person's
body, mind and heart. Discussions on nature versus nurture are sometimes framed
as heredity vs environment.

In biology and ecology, the environment is all the natural materials and living things,
including sunlight. This is also called the natural environment. Some people call
themselves environmentalists. They think we must protect the environment, to keep it
safe. Things in the natural environment that we value are called natural resources. For
example; fish, sunlight, and forests. These are renewable resources because they come
back naturally when we use them. Non-renewable resources are important things in
the environment that are limited for example, ores and fossil fuels. Some things in the
natural environment can kill people, such as lightning.

Environment is defined as the total planetary inheritance and the totality of all
resources. It includes all the biotic and abiotic factors that influence each other. While
all living elements- the birds, animals, plants, fisheries etc.-are biotic elements, abiotic
elements include air, water, sunlight etc. A study of the environment then calls for a
study of the inter-relationship between these biotic and abiotic components of the
environment.

Environment is the events and culture that a person lived in. A person's beliefs and
actions are dependent on his environment. For example, Thomas Jefferson and Julius

33
Caesar owned slaves. Modern people mostly think it's wrong to own slaves. But in
Jefferson's and Caesar's environments slavery was normal. So, their actions did not
look as wrong in their societies.

The environment is something you are very familiar with. It's everything that makes
up our surroundings and affects our ability to live on the earth—the air we breathe the
water that covers most of the earth's surface, the plants, and animals around us, and
much more.

In recent years, scientists have been carefully examining the ways that people affect
the environment. They have found that we are causing air pollution, deforestation,
acid rain, and other problems that are dangerous both to the earth and to ourselves.
These days, when you hear people talk about “the environment”, they are often
referring to the overall condition of our planet, or how healthy it is.

Oil impacts to the beach environment of Grand Isle, Louisiana. Oil and other
chemicals can get into sediments, impacting large coastal areas, threatening human
health, and reducing the economic well being of regions that depend on a healthy
coastal environment.

POTENTIAL OF WASH TO AQUATIC LIFE -THE MARINE NATURE.

Our ocean and coastal areas provide us with a lot – from food, places to boat and
swim, and wildlife to enjoy…the list goes on. So, when these areas become polluted
and unhealthy, it isn’t just bad for the environment, it’s also bad for us. At NOS,
scientists, economists, and other experts are busy monitoring, assessing, and working
to clean up contaminants in the environment.

A wide range of chemicals can contaminate our water, land, or air, impacting the
environment and our health. Most contaminants enter the environment from industrial
and commercial facilities; oil and chemical spills; non-point sources such as roads,
parking lots, and storm drains; and wastewater treatment plants and sewage systems.
Many hazardous waste sites and industrial facilities have been contaminated for
decades and continue to affect the environment.

Contaminants in the environment can look and smell pretty nasty, but their impacts go
beyond just aesthetics. Some pollutants resist breakdown and accumulate in the food
chain. These pollutants can be consumed or absorbed by fish and wildlife, which in

34
turn may be eaten by us. Chemicals can also get into sediments, impacting large
coastal areas, threatening human health, and reducing the economic well being of
regions that depend on a healthy coastal environment.

Being able to clean up and restore areas that have been impacted by contaminants
requires tools tailored to the needs of specific regions. NOS has developed a range of
tools to help coastal communities meet their needs. For example, following the
Deepwater Horizon oil spill incident in the Gulf of Mexico, NOAA worked with
partners to launch the Environmental Response Management Application (ERMA®)
Gulf Response, an online mapping tool that delivers environmental resource managers
the near-real-time information and data necessary to make informed decisions for
environmental response. The site uses the Environmental Response Management
Application, a web-based geographic information system platform developed by
NOAA and the University of New Hampshire’s Coastal Response Research Center.
NOS also offers a number of assessment tools and guidance to help coastal decision
makers understand the implications of contaminated sediments.

Harmful chemical pollution and excess nutrient runoff are serious threats to the
coastal environment. NOS scientists are conducting research to help detect and predict
how this pollution will impact coastal resources. For example, at the National Centers
for Coastal Ocean Science, scientists are evaluating the effects of single contaminants
and contaminant mixtures, conducting toxicity-testing with single species, and
conducting research in controlled conditions to assess contaminant impacts on
biological communities. Scientists are also looking at how environmental and human
stressors impact bottlenose dolphin populations.

When contaminants threaten or harm aquatic species, make them unsafe to eat, or
degrade their habitat, NOS experts work with partners to evaluate risks and injuries,
develop strategies to reduce contaminant loads, and reduce the risk to species. The
experts also monitor the effectiveness of cleanup actions and design and implement
projects to restore natural resources. At larger waste sites and after oil spills, NOS
scientists and economists conduct natural resource damage assessments to determine
the nature and extent of harm to natural resources and restoration necessary to bring
the resources to a healthier state. NOS works with the parties responsible for the
contamination to ensure that injured coastal and marine resources are restored.

35
When pollution comes from a source that can't be tied to a specific location, we call it
“nonpoint source pollution.” This kind of pollution occurs when leaking septic tanks
or storm water runoff that has picked up things like sediment, fertilizer, pet waste, or
oil drain into streams and rivers that empty into our estuaries and coastal waters. To
address this polluted runoff, NOAA and the Environmental Protection Agency jointly
administer the Coastal Nonpoint Pollution Control Program. Under the program, all
states and territories with approved coastal zone management programs are required
to develop and implement coastal programs to reduce the amount of nonpoint source
pollution entering our waterways.

2.3 Review of Critical Literature

From the studies evaluated there have been gaps which have been left by the previous
researchers, which need to be filled on the issue of finance, cost reduction, Health and
Environment? Although the authors come up with different ways in which the
importance of water sanitation and Hygiene in general it was clear that they did not
indicate how the importance of finance and cost reduction affect water sanitation and
Hygiene. The study did not major on the water industry, which could be of great
importance in the improvement of the same at household’s level and in the whole
country. Study was carried out to fill the gap on how water sanitation and Hygiene at
households’ levels was affected by the identified factors above.

Finance is usually the major constraint in any household set up. Where finance is
easily available, it usually makes it possible for the household, to pay a piece of soap
and enable the household to conduct their hygiene promotion activities with ease.
Pandey (2005), it also determines the performance of any household. Without finance,
the tactical level family cannot implement the changes and need of a household
effectively.

Cost reduction provides guidelines that ensure the smooth operations of a business.
The guidelines can at times hinder or improve the implementation of tactical plans
thereby becoming a challenge in the tactical level operations. It is easier to achieve
household goal where the policies are favorable vice versa (Sherman, 1989).
However, the study has failed to show us how Cost reduction affects the importance
of water sanitation and hygiene at household level. And therefore, the study was
conducted to fill the gaps that by the previous researchers.

36
Jalenga (2005), says changing a Health involves equated with the absence of disease –
would lead to a definition of the promotion of health as an effort to remove diseases
and diminish the numbers of individuals who suffer from them. The involvement of
functioning in the definition of health would be reflected in defining the promotion of
health as a process by which the capacity of individuals to cope will be enhanced and
strengthened, for example by regular and obligatory physical exercise. Both of these
definitions would lead to recommendations to improve the treatment of diseases, and
to remove risks factors that might lead to them – such as sedentary life style, smoking,
bad eating habits and insufficient application of hygienic measures such as washing
one’s hands before meals.

Mentzer (2001), the environment is something you are very familiar with. It's
everything that makes up our surroundings and affects our ability to live on the
earth—the air we breathe the water that covers most of the earth's surface, the plants
and animals around us, and much more. The past researchers failed to show the how
WASH affect the Environment.

2.4 Summary of Gaps to be filled

The study therefore aimed at filling the gaps identified in previous study by
investigating very concept through to be creating problems, while explaining the gap
in the current coverage (access and availability) of safe drinking water, sanitation
facilities, hygiene practices, knowledge and attitudes related to WASH within the
targeted communities.
The insecurity hitch at household level may be alleviated by outsourcing some of the
organization’s activity like insecure operation areas hinder services in the field
locations.
Road inaccessibility hinder Vehicle mobility and spoil vehicles and maintenance cost
are higher.
Natural calamities like floods which hinder operation of activities
Financial cost encounter by the communities to create water and sanitation access at
household level.
Cost reduction provides guidelines that ensure the smooth operations of a business.
The guidelines help to reduce the running cost and save on resources that are used to
deliver clean water to the society.

37
2.5 Conceptual Framework
This section prospects a schematic interpretation of the conceptual framework as
shown in the figure below.

Figure 2.1 Conceptual Framework

Independent variables Dependent Variables

 Latrine’s utilization

 Socio- demographic  Safe Clean water

 Education level  Safe sanitation
 Income level  Safe Hand washing
 Social economic
status

 Culture division

INTERVENING VARIABLE

 Political instability

 Poor government
systems

 Climatic condition

 Poor sanitation set

up systems

The diagram above indicates three variables namely, independent, intervening and
dependant variables. Where under independent variables, factors like socioeconomic,
socio-demographic, education level, latrines utilization causes diarrhoea among under
5 years children followed by intervening variables, political instability also indirectly
influences diarrhoea among children because children under 5 years will be exposed
to poor feeding and unsafe water sources, lastly in the dependant variable, we have
outcomes like safe clean water, safe sanitation and safe handwashing that affect the

38
status of Water, Sanitation and Hygiene (WASH) coverage at household level in
Jonglei State among beneficiaries of RFSP.
2.5.1 Latrine Utilization
A Latrine is a toilet or a simple facility that is used as a toilet within a sanitation
system.
Latrine utilization is the actual behaviour in a practice of regularly using existing
latrines for safe disposal of excreta. Latrine utilization is common problem in semi-
urban areas of developing countries. When latrines are not properly used then this
will lead to spread of diseases like diarrhoea which affect children under 5 years and
elderly ones at house level. Most of latrine are not properly use and remain dirty
which attract flies at household’s level.

2.5.2 Education level.

Education level is the academic credential or degree obtained from an institution.

Education is the process of facilitating learning, or the acquisition

of knowledge, skills, values, morals, beliefs, and habits.

Educational methods include teaching, training, storytelling, discussion and

directed research. Education frequently takes place under the guidance of educators,
however learners can also educate themselves. Education can take place
in formal or informal settings and any experience that has a formative effect on the
way one thinks, feels, or acts may be considered educational

2.5.3 Income level.

Income is money or the equivalent value that an individual or business receives,
usually in exchange for providing a good or service or through investing capital. Lack
of income can lead to poor sanitation facilities, shortage of water as well as poor
hygiene at household level.

2.5.4 Socioeconomic status.

Socioeconomic status is the social standing or class of an individual or group. It is

often measured as a combination of education, income, and occupation. Examinations
of socioeconomic status often reveal inequities in access to resources, plus issues
related to privilege, power, and control. This affect water, sanitation, and hygiene at
household level because poor economy led to poor sanitation facilities.

39
Important factors. Income refers to wages, salaries, profits, rents, and any flow of
earnings received. Income can also come in the form of unemployment or Education.
Occupation.

2.5.5 Culture Division

Culture is a term that refers to a large and diverse set of mostly intangible aspects of
social life. According to sociologists, culture consists of the values, beliefs, systems
of language, communication, and practices that people share and that can be used to
define them as a collective.
Driven by a shared passion for “innovation, community, integrity and inclusivity”,
this partnership is further proof that football, or soccer, is cementing itself as the sport
du jour in North America, aided undeniably by the wave of ultra-culture sweeping its
way coast to coast. Cultures affect Water sanitation and hygiene as some
communities do not wants to accumulate feces in the latrines at the same place. Some
cultures also do not want to drink water from the boreholes but rather from the river.

40
 CHAPTER THREE
RESEARCH DESIGN AND METHODOLOGY
3.1 Introduction
This chapter presents description of the research methodology that shall be used to
answer questions described in chapter one of this research study. The methodology to
be used in the research study includes research design, target population, sampling
design and data collection and analysis procedures.

3.2 Research Design

The study used descriptive research design when conducting the study. Descriptive
research was used to obtain information concerning the status of the phenomena to
describe "what exists" with respect to variables or conditions in The Catholic Relief
Services situation. This method involved range from the study survey which describes
the status quo, the correlation study which investigates the relationship between
variables. Descriptive studies are not only restricted to fact finding but may often
result in the formation of important principles of knowledge and solution to
significant problems. They are more than just a collection of data since they involve
measurement, classification, analysis, and interpretation (David, 2005).

3.3 Target Population

Schindlers (2003), described the target population as the complete set of individual’s
areas of objects with some common characteristics to which the researcher wants to
generalize the result of the study. According to Kothari (2004), target population is a
universal set of the study of all members of real or hypothetical set of people, events,
or objects to which an investigator wishes to generalize the result. In this case the
target population was 356 HH beneficiaries from The Resilience Food security
beneficiaries where it comprised levels of villages, Bomas and Payams of Jonglei
State.
3.4 Sample Design
A sample is a representative of population. The sampling technique adopted was
stratified random sampling method. It was used since it is reviewed to be free from
biasness of population; it considered all levels of population. A sample size of 356
respondents was drawn representing 50% of the target population.

41
3.5 Data Collection Instruments and Procedure
To the study, questionnaires and secondary data were used to collect the data. The
questionnaires were structured in such a way that it obtained both qualitative and
quantitative data.
3.5.1 Primary Data
This is a list of questions that are sent to several persons seeking their responses that
can be tabulated and treated statistically. It is a form for securing answers to questions
from respondents. The researcher used both structured and unstructured questionnaire
which have both structured and semi-structured questions. There was a pre-
determined question whereby respondents were served with the questionnaire and are
given a chance to fill. The types of questions used were both open and closed ended.
Closed ended questions were used to ensure that the given answers were relevant. The
researcher phrased questions clearly to make dimensions along which respondents
were analyzed. In open-ended questions, space shall be provided by the respondent,
thus giving him/her freedom to express their feeling. This includes household
questionnaire.
The data collection team administered 356 HH questionnaires to conveniently
sampled households in Akobo, Bor, Duk and Pibor. An analysis of the composition
revealed a female/male breakdown of 48.5% / 51.5%. With CU5 constituting 30.7%
and the 5-17 years age group comprising 36.7% of the total HH composition as
summarized in the household demographics.
3.5.2 Secondary Data
Materials available in the organization, Manuals available in the organization in
relation to this study, magazines, newspapers, journals, and www (World Wide Web)
were used.
Study data were collected through secondary data, focus group discussions (FGDs),
and household questionnaires.
The researcher reviewed WASH reports which included government publications,
United Nations (UN) and NGO reports published on the South Sudan WASH
situation. These sources were used to triangulate and validate the study findings.
3.5.3 Validity and Reliability of Research Instruments
Kothari (2004), states that validity is the accuracy and meaningfulness of inferences
which are based on the research results. It is the degree through which results
obtained from the analysis of data represent the phenomenon under study while
42
reliability is a measure of the degree to which a research instrument yields consistent
results after repeated trials. It involved administering the same instrument several
times to the same group of subjects.

The research obtained authority from relevant departmental sections of the

organization to circulate questionnaires. To ensure reliability and validity
questionnaires were pre-tested on five respondents. These respondents were included
in the final study. The questionnaires were then corrected before the final distribution
is done.

3.5.4 Administration of Questionnaires

Questionnaires were used in the study which was hand-delivered and collected after a
few days. The types of questions used included both open and closed ended. Closed
ended questions were used to ensure that the given answers are relevant. The research
phrased the questions clearly to make clear dimensions along which respondents will
be analyzed. In open ended questions, space was provided for relevant explanation by
the respondents, thus giving them freedom to express their feelings. This method was
considered effective to the study in that; it created confidentiality. The presence of the
researcher was required as the questionnaire was self-administered.
3.6 Data Analysis Methods
According to Kothari (2004), data analysis procedure includes the process of
packaging the collected information putting in order and structuring its main
components in a way that the findings can be easily and effectively communicated.
After the fieldwork, before analysis, all questionnaires were adequately checked for
reliability and verification. Editing, coding, and tabulation were carried out. The data
collected will be analyzed using simple qualitative and quantitative methods and
presented using tables, figures, and charts.

43
 CHAPTER FOUR
DATA ANALYSIS, PRESENTATION, AND INTERPRETATION OF
FINDINGS.
4.1 Introduction
This chapter undertook to analyze and discuss the data collected from the respondents
in relation to research objectives and questions. Analysis was presented using
frequency tables and percentages, presented in graphs charts, and interpreted
thereafter. The open-ended questions were analyzed in qualitative nature and closed
ended questions analyzed in quantitative nature.
4.2 Presentation of Findings.
4.2.1 Response Analysis.
Table 4.1 Water access by county
borehole river Other Piped Riverbed sand well
rainwater water abstraction
County scheme
Akobo 59% 0% 1% 1% 40% 0% 0%
Bor 70% 24% 2% 0% 1% 2% 2%
Duk 100% 0% 0% 0% 0% 0% 0%
Pibor 32% 39% 0% 0% 29% 0% 0%
Total 65% 15% 1% 0% 19% 0% 0%

Source: Author (2021)

44
 Figure 4.1 Water Access by counties in Jonglei State.

Figure 4.2 Response Analysis

Source: Author (2021)

Table 4.1 and figure 4.2 above indicate the respondents who were given the
questionnaires. The main drinking water source for HHs was boreholes according to
65% of the respondents. However, 19% reported they sourced of water from the
riverbed whilst 15% fetched water from the river. A lower number of people

45
identified rainwater (1%), sand abstraction (0.48%), hand dug well (0.48%) and piped
water (0.24%) as their sources of drinking water. All Duk HHS reported boreholes as
being their principal source of water whilst this figure dropped to 32.22% in Akobo,
thereby showing county level variances in terms of access to borehole water. From the
foregoing data, it is evident that nearly 65% of the population had access to an
improved water source, a decrease of around 3% from the South Sudan 2010
Household and Health Survey (HHS) data of 68.7%. This variation could be a result
of the prolonged crisis since December 2013 that has curtailed the maintenance of
improved water sources. The FGDs revealed that women and girls were principally
responsible for water collection, with boys sometimes sharing the work.
4.2.2 Access to water.
Regarding the amount of water collected, 52.5% of HHs reported collecting 1-3 jerry
cans per day, while 31.7% collected 4-6 jerry cans, 10.4% collected 7-9 jerry cans and
only 5.3% collected more than 9 jerry cans. The average volume of water collected
daily by these households was 80 litres which translated to 9 litres per person per day
(using average household size of 9 from the study) and falls short of the SPHERE
standards of 15 litres per day. However, 71.8% of HHs indicated that the water they
collected was adequate whilst only 28.2% indicated that it was inadequate. The study
findings indicated that 85.7% of the households that fetched water from the river,
73.5% from the borehole and 52.5% from the riverbed reported that their water was
adequate. Scarcity of water containers, long distances from water sources and limited
Water availability were the major challenges that HHs reported which limited their
collection of adequate volumes of water.
4.2.3 Gender Response
Table 4.3 Gender Response
Gender Frequency Percentage
Male 48 48.5
Female 52 51.5
Total 100 100
Source: Author (2021)

46
Figure 4.3 Gender Response

Gender Response by Frequency

52

100 Female
Male
48 Total

Source: Author (2021)

Figure 4.4 Gender Response

SOURCE: AUTHOR (2021)

The table 4.3, figure 4.3, and figure 4.4 indicate the response on gender. The analysis
clearly shows that the RFSP beneficiaries had a higher number of females compared
to males. The females were represented by 51.5% respondents while the males being
the minority were represented by 48.5% of the total respondents. This implies that the
1/3 gender rule was met by the organization.

47
4.2.4 Age Bracket
Table 4.4 Age Bracket
Age group Males Females Total
CU5 16.4% 14.3% 30.70%
5- 17 years 18.7% 18.0% 36.70%
above 18 years 16.3% 16.2% 32.50%
Total 51.5% 48.5% 100.00%
Source: Author (2021)
Focus group discussions - Three FGDs were conducted in Akobo, Pibor and Bor
counties with hygiene promoters and water point user communities to provide
qualitative data on community perceptions on the WASH situation.
Figure 4.4 Age Bracket

0.4 0.367
0.35 0.325
0.307
0.3
0.25
0.1870.18 Sum of Males
0.2 0.1630.162 0.164
0.143 Sum of Females
0.15
Sum of Total
0.1
0.05
0
5- 17 years above 18 years CU5

Source: Author (2021)

48
Figure 4.5

Males

16.40%

51.50% 18.70%

16.30%

Source: Author (2021)

Figure 4.6

Source: Author (2021).

According to table 4.4, figure 4.4 and figure 4.5 above, indicates the ages of the
respondents analyzed. From the analysis 36.70% of the total respondents being the
majority were ages between 5-17 years, CU-5 years were represented by 30.70%,
above 18 years were 32.50% respectively. From the above study it can be deduced
that most of the respondents were between the ages of 5-17 years, young and not
energetic to work.

49
Focus group discussions - Three FGDs were conducted in Akobo, Pibor and Bor
counties with hygiene promoters and water point user communities to provide
qualitative data on community perceptions on the WASH situation.
4.2.5 SOCIAL ECONOMIC FACTORS.
Education levels: Research findings by Mpanzi and Mnyika (2005), who explained
that, analysis of knowledge levels on cholera prevention and control was lagging
behind in the study population. Consequently, WHO (2008) reported that acquiring
knowledge of cholera is an important strategy in the control of cholera. However,
implementing certain interventions in high-risk groups with poor knowledge of an
attitudes toward cholera is not easy.
Table 4.5 Highest Level of Education in Jonglei State.
Level of education Frequency Percentage
Primary 180 46.8
Secondary 57 14.7
University 19 5
Others 70 18.2
Illiterate 58 15.3
Table above shows the level of education of respondents
Source: Author (2021)

50
Figure 4.5 Highest Level of Education

Source: Author (2021)

Figure 4.6 Highest Level of Education.

Source: Author (2017)

The above table 4.5 and figure 4.5 indicate the response on the highest education level
in Jonglei state as per the study during respondents’ response. The response from
primary level was 46.8%, secondary level was 14.7% while the response of university
level was 5% being the minority and those who had illiterate qualification were 15.3%
while others were 18.2%. From the analysis therefore it can be concluded that

51
majority of the respondents had primary qualification indicating good level of literacy
at the household’s level. This mean there is much need of education to curve the
situation of Hygiene and sanitation at household’s level in Jonglei state.
4.2.6 Adequacy of water by source.
Table. 4.6
Do the facilities provide
adequate water?
Water source No Yes
borehole 26% 74%
dam/river 14% 86%
other 100% 0%
riverbed 48% 53%
sand abstraction 100% 0%
Overall 28% 72%
Source: Author (2021)

Figure 4.6

Source: Author (2021)

52
Figure 4.7 Adequacy of Water by Source

Water Source

14%
26%
100%

100%

48%

borehole dam/river other riverbed sand abstraction sand abstraction Overall

Source: Author (2021)

According to table 4.6 and figure 4.6 above shows the category of respondents in the
rural communities. From the analysis 86% of the total respondents fetch water from
rivers/dams, 74% fetch water from boreholes while the remaining 53% fetch water
from riverbed. Based on the study findings it can be concluded that majority of the
respondents fetch water from rivers/dams.

4.2.7 Economic status.

Jonglei is characterized by low-income levels with major economic activities
including; cattle keeping, crop growing and fishing.

Table. 4.7
Activity Frequency Percentage
Cattle keeping 165 42.9
Crop growing 107 27.8
Fishing 111 29.3
Total 100
Source: Author (2021

53
Figure 4.7: A Bar graph showing economic status In Jonglei State

Source: Author (2021)

Figure 4.8: A pie chart showing the major economic activities in Jonglei Sate

Source: Author (2021)

According to table 4.7 and figure 4.7 above shows the category of respondents in the
rural communities of Jonglei State. From the analysis 42.9% of the total respondents
are cattle keepers, 27.8% do farming or crop growers while 29.3% are fishermen.
Based on the study findings it can be concluded that majority of the respondents are
cattle keepers from Jonglei State. It can also be concluded that among the nomad,

54
communities there is low practice of safe sanitation and hygiene as well as drinking
from safe clean water sources.
4.2.8 Containers used for transportation and storage of water.
Table 4.8
Type of container transportation storage
container with lid (jerry can narrow mouthed) 52% 33%
container with and without lid 13% 17%
open container (bucket) 21% 24%
other 2% 4%
no container 12% 22%
Total 100 100
Source: Author (2021)

Figure 4.8

Total

other

open container… Sum of

transportation
no container
Sum of storage
container with lid…

container with…

0% 50% 100%

Source: Author (2021)

Table 4.8 and figure 4.8 above indicates the importance of water transportation and
storage on Water Sanitation and Hygiene. From the analysis 52% transport water in
container with lid while 33% store water in container with lid, 21% transport water,
using open bucket while 24% store water in open bucket. 13% transport water in
container with and without lid while 17% store water in container with and without
lid. 12% use no container for transportation while 22% use no container for storage of
water. Based on the study most of the respondents use water containers to transport
and store water at household level. Therefore, it can be concluded that rural

55
communities still need to be given awareness on water safe water transportation and
storage at least with covered water containers.
Figure 4.9: Methods of collecting water from container.

Source: Author (2021)

Table 4.8 and figure 4.8 above indicates the importance of collecting water from
containers on Water Sanitation and Hygiene. Containers are important in ensuring
water is kept clean before consumption. The data from HH interviews revealed that
51.0% used to pour water for drinking, 32.3% used both pouring and Deeping
method, 6.5% used dipping, but only 1.8% used other means of water collection for
drinking purposes. From most households used to pour water from drinking
containers for consumption.
4.2 9 Containers used for collecting and storing water.
Containers are important in ensuring water is kept clean before consumption. The data
from HH interviews revealed that 52% used jerry cans to collect water but only 33%
used the same for storage. However, 13% used containers with and without lids for
collecting water but 17% used them for storage. More than 21% of the households
used open containers to collect and store water. More than 24% of HHs stored water
partially uncovered which could lead to contamination.
Table 4.9 Clarity and palatability of water by county.
County clarity of water palatability of water
Akobo 60% 70%
Bor 59% 65%
Duk 60% 76%

56
 Pibor 60% 70%
Overall 59% 70%
Source: Author (2021)

Figure 4.9 Water palatability and clarity.

Sum of palatability and clarity of water

0.6, 20% 0.6, 20%

0.59, 20% 0.59, 20%

0.6, 20%

Source: Author (2021)

Table 4.9 and figure 4.9 showed that 59% of respondents indicated that the water that
they collected was clear and there were no marked variations on this perception across
counties. When asked about water palatability, 70% of respondents indicated that the
water they collected was palatable and this varied from as high as 76% in Duk to
around 65% in Bor. The results also showed that most of the respondents (77%)
considered that river water was more palatable than borehole (73%) while 74%
considered that river water was clear compared to 64% for boreholes. This can be
interpreted to show that the households would prefer river water to borehole water
based on historical utilization.
4.3.0 Functionality of Water Point User Committees (WPUCs).
Overall, the majority (71.8%) of respondents reported that the water points they used
had functional WPUCs. The respondents who used boreholes (77.2%), wells (50%),
sand abstraction (100%), piped water (100%), river water (67.8%), and other sources
(66.7%) reported that WPUCs were in place.
As boreholes and wells constituted the main water sources for the sample areas, the
survey indicates a gap of sustainability for these schemes. Some communities using
improved water sources had functional WPUCs and some HHs paid five South

57
Sudanese pounds (5SSP) per month. Community resistance to paying fees was
expressed in the view that water was a gift from God for which no payment should be
required.
Figure 4.3

Water Sources
120%

100%
100%

80%

60%

40%

20%

Source: Author 2021

Table 4.3 and figure 4.3 indicates water sources by the rural communities. From the
analysis majority of the respondents (86%) obtained water from the dam/river, 74%
obtained water from Boreholes, 53% get water from riverbed and other sources was
0%. They also reported that the water points they used had functional WPUCs.
4.3.1 Diarrhoea cases reported in two weeks prior to the study.
One of the manifestations of poor water quality and unhygienic conditions is the
prevalence of diarrhoea. Since children are most susceptible to disease, measuring
diarrheal incidents in CU5 could indicate the locations most vulnerable to outbreaks.
In the study area, 49% of respondents reported incidents of diarrhoea in the two
weeks prior to the survey. The FGDs revealed that diarrheal diseases were particularly
common among CU5 because they do not wash their hands often enough as there
were no handwashing facilities available. Diarrhoea was seldom treated medically by
respondents but usually by local herbs.
4.3.2 Understanding of the causes of diarrhoea.
Most of the respondents identified contaminated water (42.1%) as the main cause of
diarrhoea, unsafe food (30.6%), flies (36.2%), dirty hands (27.0%), open defecation
(22.8%), and God’s will (18.0%) while 10.1% did not know any cause of diarrhoea.

58
Overall, many of the respondents reported that the major causes of diarrhoea were
unsafe water and poor sanitation facilities.
4.3.3 Hand washing at critical times.
Most of the respondents (94.5%) reported that they wash their hands at critical times.
These times included before eating food (94.4%), before preparing food (71.1%),
after eating (68.8%), after handling baby’s excreta (60.7%), after handling rubbish
(53.9%), after visiting the latrine (46.3%), and before feeding infants (41.9%).
4.3.4 Reason for washing hands.
Respondents gave various reasons for washing hands, including the majority (80.1%)
who reported washing their hands to be clean, 69.7% who washed their hands to
prevent germs which may cause diseases and 53.7% who did so to remove bad odor.
4.3.5 Hand washing methods.
The survey results show that most of the respondents (56.6%) used water only for
hand washing whilst 43.8% used water and soap and 34.8% used water and ash. A
small number of respondents reported using sand (5.3%) or tree leaves (0.6%) while
only 0.3% respondents used other means. Hand washing with soap is the most
effective low-cost intervention to prevent diarrhoea and has been calculated to save a
million lives (Curtis 2003). According to Curtis, hand washing may be at least as
effective as some vaccines currently under development.
4.3.6 Sources of hygiene messages for communities.
The study shows that the majority of the respondents (46.9%) reported receiving
hygiene messages from CRS and other NGOs, 17.4% from health extension workers,
13.2% from community health volunteers, 12.4% had heard the message from the
radio/television, 1.4% from water sanitation hygiene committees (WASHCOs) and
1.7% from others sources. Most of the community members (54.5%) indicated that
they had received hand washing messages, 47.2% had received messages on diarrhea
disease prevention, 37.6% on safe excreta disposal, 34.3% on safe water chain and
35.7% on safe food handling.
4.3.7 Environmental Sanitation (Rubbish pits).
Less than half of HHs (42.5%) reported having rubbish pits. Of those who did have
rubbish pits, 15% of respondents had them within their HH compound, 72% within 10
meters of their kitchen and 13% had the pits located more than 10 meters from the
kitchen. According to the information from the respondents the depth of rubbish pit
varied from ground level to 3 meters below ground. Just over half of respondents
59
(57.3%) reported that their rubbish pit depths ranged between 1.0 and 1.5 meters,
while 31.1% reported that their pits were between 1.6 and 2.0 meters deep and 6.8%
indicated that their rubbish pits were between 2.1 to 3 metres deep. HHs managed
rubbish by burning (84.5 %), by burying (10.1 %) while only 4.7% took no action.
HHs without rubbish pits reported that they dumped their garbage in the bush
(40.5%), dumped it in the compound backyard (18%) or burnt it (17.6%). Other
garbage disposal methods employed by HHs included throwing it into the river
(9.5%), whilst others used both burning and burying (6.1%). The remainder of HHs
used a combination of the above methods.
Safe disposal of human excreta is the first step in preventing faecal-oral and other
routes of disease transmission. The construction of toilets is one of a few interventions
essential for building people's dignity and safety, while catalyzing good health and
well-being. Cross-country studies also show that the method of disposing of excreta is
one of the strongest determinants of child survival: the transition from unimproved to
improved sanitation reduces overall child mortality by about a third (WHO 2000;
World Bank 2003; UNDP 2006).

4.3.8 Usage of sanitation facilities by sex.

The principal sanitation facility that most respondents (83% of men, women, and
children) reported using was the bush while only 12.5% used latrines. The FGDs
revealed that the community had limited knowledge on the advantages of having HH
latrines or of the negative consequences of open defecation. Few HHs consistently
(18.8%) or irregularly (12.5 %) practiced the cat method while more than 68.7% of
HHs engaged in open defecation.

4.3.9 Sanitation and hand washing facilities.

Most respondents who use latrines had reported that their latrines were maintained
clean and had handwashing facilities and soap available. Respondents who flush
toilets had also reported that the flush toilets were maintained clean, with
handwashing facilities but without soap. Respondents who owned VIPs reported that
the VIPs were maintained clean and had handwashing facilities with no soap.

60
 CHAPTER FIVE
SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATION
5.1 Introduction
This chapter represents the study results in terms of introduction finding answers to
research questions, study recommendations, conclusion, and room for further study

5.2 Summary of Findings.

5.2.1To what extent is finance important to water sanitation and Hygiene?
On the extent to which finance is important to water sanitation and Hygiene, 13% of
the total respondents rated the effect of finance on strategic planning as very high,
because they have no containers for water storage due to shortage of money. 87% did
not store water separately from reserved water for domestic use due to shortage of
money for buying water containers.13% rated low with access to latrine and 87%
rated high with no access to latrine as a result of no money to buy construction
materials for latrine construction.

5.2.2 To what extent do Coverage of water reached at household level as it is

important to water sanitation and Hygiene

It was found out that water coverage at household’s level is important to water
sanitation and Hygiene sector, 64.6% of the total respondents rated very high water
from the boreholes and 35.4% rated low water from the river and wells.

5.2.3 What is the important of Sanitation to water sanitation and Hygiene

Sector?
Based on the findings, Sanitation is important to water sanitation and Hygiene, as
asserted by most of the respondents who rated 12.3%, do practice CAT method,
68.7% rated very high, do not practice CAT method, 22.8% practice open defecation
and 13 % have access to sanitation practices.
Improved sanitation also helps the environment by reducing the rate of pollution.
Clean drinking water and good sanitation would not prevent infections without
practicing good hygiene. A simple habit of handwashing goes a long way towards
preventing diseases. The stored water supply may also serve as a source of infection
in the absence of hygiene.

61
5.2.4 To what extent does Hygiene affect Environment?
On the extent to which Hygiene affect Environment is that 67% being the majority
response rated high that used water only and 37% rated very low that used water and
soap only.
Practically, poor hygiene affects human health through water pollution by human and
animal wastes disposal, food contamination, and poor housing.

5.3 Conclusions

Based on the findings, the researcher confirmed that coverage of water, Sanitation and
hygiene are all important in Water sanitation and Hygiene. This section summarizes
the study findings from the primary data collection and uses secondary data as
reference points. Data presented on this section were collected through household
interviews, FGDs and secondary data.

5.4 Recommendations
5.4.1 Status of Water Sanitation and Hygiene
This KAP study present an opportunity for researcher to reflect on the current status
of water, sanitation and hygiene access and practices and to determine what actions
should be initiated to achieve improvement and realize the intermediate results.
In addition to the need for physical access to improved water and sanitation by
communities the data also indicate the need for more intensive community education
to increase knowledge and overcome barriers to improved water, sanitation, and
hygiene access. For example, among households without a latrine, an average of 88%
in the sampled counties stated that the main reason for not having a latrine was not
knowing how to build one.
Community mobilization, sensitization, and demonstration of models for constructing
low-cost latrines accompanied by targeted community and HH education activities
could contribute to lowering this barrier to latrine access.
The KAP study indicated a significant gap in access to potable water as almost 35.4%
of the total sampled community are still using river water and wells for drinking. The
majority of sampled HHs (87%) were still practicing open defecation, and 67% of the
sampled HHs did not use soap to wash their hands at critical times. These data
demonstrate that access to safe water, the practice of safe sanitation and improved
hygiene knowledge need interventions which can improve community hygiene and

62
sanitation awareness and transform individual and HH behaviour.

5.4.2 Further Interventions

The study recommends that based on the findings of this KAP study, below are
specific recommendations for future interventions:
Educate communities on methods of treating water to make it safe for drinking.
Education should target women as they are primarily responsible for water collection
and management at household level.
Provide intensive health education to communities about the importance of keeping
the water chain intact including the importance of using separate water storage for
drinking water.
Promote the construction and the use of HH latrines.
Disseminate information to HHs on methods of safe water chain management.
Develop a comprehensive communication strategy on hygiene awareness and initiate
behavioural change interventions.

5.4.3 Health Status.

It was recommended that Water Sanitation and Hygiene should be a priority to ensure
that everybody at household level is healthy.

5.4.4 Environment.
It was recommended that Water Sanitation and Hygiene is everybody’s responsibility
to ensure safe and sound surrounding environment.

5.5 Suggestions for Further Study.

The study observed a need for further research since the study could not exhaust all
the importance of WASH at household’s level or humanitarian sector. Areas
suggested for further research should include the use of more variables such as
Improved Living Standards on education from awareness, change behaviours and any
other variables befitting the research under study.

63
 REFERENCES

 Akter T, Ali AM (2014). Factors influencing knowledge and practice of

Hygiene in Water, Sanitation and Hygiene (WASH) programme Areas of
Bangladesh Rural Advancement Committee, pp
 Assefa M, Kumie A (2014). Assessment of factors influencing hygiene
behaviour among school children in Mereb Leke District, Northern Ethiopia: a
cross-sectional study. BMC Publ. Health 14(1):1000.
 Aunger R, Schmidt WP, Ranpura A, Coombes Y, Maina PM, Matiko CN
(2010) Three kinds of psychological determinants for hand-washing behaviour
in Kenya. Soc. Sci. Med. 70(3):383-391. Core H (2002). Hand Hygiene in
Healthcare Settings: An Overview of health care hand washing. pp. 1-27.
 Core H (2002). Hand Hygiene in Healthcare Settings: An Overview of Health
care hand washing. pp. 1-27.
 Cairncross and Valdmanis (2006), reported that most diarrhoeal diseases are
transmitted through water-washed and not waterborne routes.
 Drivers of sustained hygiene behaviour change: A case study from mid-
western Nepal.[Soc Sci Med. 2016].
 Gopal et. al. 2009). Estimates from the WHO and UNICEF show that about
1.1 billion people lack access to improved water supplies and 2.6 billion
people lack adequate sanitation worldwide
 Hamner et. al., 2006. A safe water supply has been defined as a source which
is likely to supply water which is not detrimental to health.
 Hamner et. al, 2006; O'Hara, Hannan and Genina 2008. If these sources can
provide 20 litres per capita per day at a distance which is no greater than one
kilometer from the user’s dwelling, then they are improved sources
 O'Hara, Hannan and Genina 2008; United Nations 2010). Goal 7, Target 7 C
of the MDG’s directly refers to drinking water and sanitation and aims to
reduce by half the proportion of people without these amenities
 Pittet, D. (2001). Improving adherence to hand hygiene practice: A
multidisciplinary approach. Emerging Infectious Diseases, 7, 234-40. doi:
10.3201/eid0702.010217

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 Rabbi, S. E., & Dey, N. C. (2013). Exploring the gap between handwashing
knowledge and practices in Bangladesh: A cross-sectional comparative study.
BioMed Central Public Health, 13, 89. doi: 10.1186/1471-2458-13-89.
 Setyautami T, Sermsri S, Chompikul J (2012). Proper hand washing practices
among elementary school students in Selat sub-district, Indonesia.
 Sibiya JE, Gumbo JR (2013). Knowledge, Attitude and Practices (KAP)
Survey on Water, Sanitation and Hygiene in Selected Schools in Vhembe
District, Limpopo, South Africa. pp. 2282-2295.
 Socio-cultural and behavioural factors constraining latrine adoption in rural
coastal Odisha: an exploratory qualitative study.[BMC Public Health. 2015]
 San Martin 2002; Eshcol, Mahapatra and Keshapagu 2009.Waterborne
diseases are primarily caused by human and animal faecal contamination.
 Tao, S. Y., Cheng, Y. L., Lu, Y., Hu, H. Y., & Chen, D. F. (2013).
Handwashing behaviour among Chinese adults: a cross-sectional study in five
provinces. Public Health, 127, 620-628. doi: 10.1016/j.puhe.2013.03.005

65
APPENDIX I
Consent Form.
Investigators:
Manon David Awan

Dear Sir/ Madam,

This questionnaire is intended to facilitate the study on the Topic: Knowledge
Attitude and Practice of Water Sanitation and Hygiene coverage at household level in
the rural communities of Jonglei State. The study is for academic purposes and is
carried out as partial requirement of the award of Post graduate diploma in Water
Sanitation and Hygiene of Strategia Netherlands. Your responses will be treated with
utmost confidentiality. Your input is highly appreciated.

STATEMENT OF CONSENT/ASSENT
........................................................................... has described to me what is going to
be done, the risks, the benefits involved and my rights regarding this study. I
understand that my decision to participate in this study will not alter the services that I
am seeking in this organization or any other. In the use of this information, my
identity will be concealed. I am aware that I may withdraw at any time. I understand
that by signing this form. A copy of this form will be provided to me.
………………….. Participant’s Signature or Thumbprint ……………. Age...……
Date ……………………………
Signature of Interviewer …………………………. Date….............

i
 Appendix 2: Questionnaires for respondents
A. HOUSEHOLD CHARACTERISTICS
County: __________________
Payam:_______________
Boma: _______________
Village_______________
Survey #: ______________

Respondent identity:
 Mother / Female head of house
 Female over 15 years
 Male over 15 years

Respondent’s level of education

Can’t read and write

 Read/write-informal education
Primary (1-8)
 Secondary
 Tertiary/College/University

1. What is the total family size of this household?

____ People.

2. How many of them are:

AGE GROUP FEMALE MALE

ELDERLY, OVER 65 YEARS

WORKING AGE ADULTS (18-64

AGE YEARS)

SCHOOL AGE CHILDREN (5-17)

CHILDREN UNDER 5 YEARS

Check that the numbers add up to question 1

ii
How many people in your household can read? _____

3. What is the main source of drinking water for this household? (ONLY CHOOSE
ONE :)
 Tap stand
 Hand pump
 Open well or unprotected spring
 Protected well or spring
 Rainwater collection
 Open River or pond
 Water sellers
 Other _____________________________

4. Why do you collect water from this source?

It is safe to drink
It is near to my home
It is the only choice I have
It has no disease in it
Others (specify)

5. How long do you travel/walk to reach your nearest water point?

Less than 250meter

250m to 500meter
500 to 750meter
750 to 1000meter

6. How long does it take you to travel one way to collect water from the source?

 More than 60 Minutes

30-60 Minutes
0-30 Minutes

iii
Don’t know/don’t remember

7. How many months do you have access to this source during the year (12 months)?

12 months
8 months
6 months
3 months
Less than 3 months
8. In the last 2 weeks has the water from this source been unavailable for at least 1
whole day?

 Yes
 No
 Don’t know
9. When this source is not available at any time, what other source of drinking water
do you use for members of this household?

 Tap stand
 Hand pump
 Open well or unprotected spring
 Protected well or spring
 Rainwater collection
 Open River or pond
 Water sellers
 Other _____________________________

10. Do you treat your water in any way to make it safer for drinking?

 Yes
 No

11. If yes, what do you usually do to the water to make it safer for drinking?

 Boiling
 Strain through a cloth

iv
 Let it stand and settle/sedimentation
 Add bleach/water treatment chemicals
 Water filter (Bio sand/ceramic)
 Solar disinfection
 Other_________

12. When did you treat, your drinking water the last time using this method?

 Today/Yesterday
Over one day age/less than one week
Over one week/less than one month
 One month ago, or more
 Don’t remember

13. How many containers of water did you collect yesterday for household use?

3-liter jerry cans_______

5-liter jerry cans_______
10-liter jerry cans _______
20-liter jerry cans _______
25-liter jerry cans
Other size _____ number ________ size (liters)

14. Do you store drinking water separately?

 Yes  No

15. May I see your drinking water containers?

What number of each type of container?

 Narrow necked (less than 3cm) container
Wide necked uncovered container
Wide necked covered containers
16. When did you last clean the containers?

v
 Less than a week ago
 1 – 2 weeks ago
 More than 2 weeks ago
 Never
 Don’t know
17. What type of detergent do you use in cleaning?

 Water only
 Water and soap
 Sand
 Gravel
 Don’t know

18. Why do you clean your water containers?

keeps the water clean and safe to drink

Feel good
Avoid disease transmission
My family will be healthy
Hygiene promoters told us to
It is cultural to wash
Other (specify)______________

19. Where do you and your family pass stool / defecate?

 Family latrine
 Shared or group latrine
 Communal (public) latrine
 Open field/in the bush
 Dig small hole and cover
 Other _____________________________

vi
20. (If there is a family/shared latrine) May I see your latrine? Was a latrine seen?

 Yes  No
If yes, check all that apply:

 Latrine has feces on floor

Latrine appears unused
 Latrine structure/door is damaged
 Latrine is full (fecal matter clearly visible in pit at less than 50cm depth)

Are there any HUMAN feces seen in compound or verandah?

 Yes  No

21. How would you dispose of children’s feces?

 Latrine
 Dig hole and cover
 In open bush / outside compound
 In solid waste bin or pit
 Other _____________________________

22. When do you wash hands? [DO NOT PROMPT. Ask ‘Any other time?’ until
the respondent has no other times. Check all that are mentioned.]

 After latrine use

 Before cooking / preparing food
 Before eating
 Before feeding a baby
 After cleaning a baby’s bottom

23. Where you and your family usually wash your hands?

 Inside/near toilet facility

vii
Inside/near kitchen/cooking place
No specific place
 Other

If yes, can you show me the place?

(Please observe),

 Is water present?
 Is there a hand washing facility like tap, bucket, jerry can or tippy tap?
 Is soap or ash present?

24. What do you use to wash hands?

 Water alone
 Soap and water
 Ash
 Soil / sand
 Nothing
 Other ____________________

25. Can you show me your soap?

 if respondent produced the soap in less than 1 minute, otherwise check ‘No.’
 Yes  No

26. Can you tell me the important times to wash hands? [DO NOT PROMPT. Ask
‘Any other time?’ until the respondent has no other times.]

 After latrine use

 Before cooking / preparing food
 Before eating

viii
 Before feeding a baby
 After cleaning a baby’s bottom

27. Did anyone from the family have diarrhoea in the past two weeks?
“Where is diarrhoea defined as three or more loose stools or one loose, bloody stool
within a 24-hour period?”

Yes
No
I don’t remember

28. How do you prevent diarrhoea in your household?

 Latrine use
Hand washing
Drinking safe water
 Heating food before eating
 Other

29. What do you do to a person who has diarrhoea at home?

Give solution at home

Go to the nearest health centre
Give some herbs
Other

30. What are your most important source of information about WHAS, Health and
nutrition? (Give up to 3 answers)

CHWs/CHPs
 Friends/neighbours/family

ix
 Community leaders
 Religious leaders
 Public meetings
 Radio
 Other____________________

31. Did you receive any WASH related messages in last one month?

 Yes
 No
 Don’t remember

32. If yes, what are the key messages that you have received in a month time.

 Proper Hand washing

 Latrine construction and proper utilization
 Safe water storage and management
 Food hygiene
 Others ________________

33. Have you been visited by any health workers/hygiene promoters in the last
month?
 Yes  No

34. Do you have a radio?

 Yes  No

35. How often do you listen to it?

 Every day
 At least once a week
 At least once a month

x
 Less often or never

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