Water and Sanitation Program: technical Paper 73475 Global Scaling Up Rural Sanitation Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Bertha Briceño and Ahmad Yusuf September 2012 The Water and Sanitation Program is a multi-donor partnership administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. Bertha Briceño and Ahmad Yusuf, Water and Sanitation Program Today, 2.5 billion people live without access to improved sanitation. Of these, 75 percent live in rural communities. To address this challenge, WSP is working with governments and local private sectors to build capacity and strengthen performance monitoring, policy, financing, and other components needed to develop and institutionalize large scale, sustainable rural sanitation programs. With a focus on building a rigorous evidence base to support replication, WSP combines Community-Led Total Sanitation, behavior change communication, and sanitation marketing to generate sanitation demand and strengthen the supply of sanitation products and services, leading to improved health for people in rural areas. For more information, please visit www.wsp.org/scalingupsanitation. This technical paper is one in a series of knowledge products designed to showcase project findings, assessments, and lessons learned through WSP’s Scaling Up Rural Sanitation initiatives. This paper is conceived as a work in progress to encourage the exchange of ideas about development issues. For more information please email Bertha Briceño and Ahmad Yusuf at wsp@worldbank.org or visit www.wsp.org. WSP is a multi-donor partnership created in 1978 and administered by the World Bank to support poor people in obtaining affordable, safe, and sustainable access to water and sanitation services. WSP’s donors include Australia, Austria, Canada, Denmark, Finland, France, the Bill & Melinda Gates Foundation, Ireland, Luxembourg, Netherlands, Norway, Sweden, Switzerland, United Kingdom, United States, and the World Bank. WSP reports are published to communicate the results of WSP’s work to the development community. Some sources cited might be informal documents that are not readily available. The findings, interpretations, and conclusions expressed herein are entirely those of the author and should not be attributed to the World Bank or its affiliated organizations, or to members of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The map was produced by the Map Design Unit of the World Bank. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank Group concerning the legal status of any territory or the endorsement or acceptance of such boundaries. © 2012 Water and Sanitation Program Global Scaling Up Rural Sanitation Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Bertha Briceño and Ahmad Yusuf September 2012 Acknowledgments The Tanzania Impact Evaluation Team oversees the in-country design and field activities; investigators include Sebastian Martinez, Bertha Briceño, Aidan Co- ville, and (in its early stages) Alicia Salvatore. The survey analyzed in this report was intended to serve as a baseline to the impact evaluation of the program but unanticipated problems with reliability of data resulted in the cancelation of field work in five out of the 10 districts originally planned and the impossibility of using the data to validate the randomized design, as it was originally intended. The project’s global impact evaluation task team is led by Bertha Briceño (in its early stages, it was led by Jack Molyneaux), together with Alexandra Orsola-Vidal and Claire Chase. Professor Paul Gertler has provided guidance and advice through- out the study. Advisors also include Sebastian Galiani, John M. Colford, Benjamin Arnold, and Pavani Ram. The authors are grateful to Jason A. Cardosi, Patrick Mwakilama, Kaposo Mwambuli, and Yolande Coombes, the country task team for project imple- mentation in Tanzania; to Wambui Gichuri, former Regional Team Leader for the WSP-Africa region; and to Eduardo Perez, overall task team leader. Generous financial support was provided by the Bill and Melinda Gates Foundation. ii Scaling Up Rural Sanitation Executive Summary Since 2007, the Water and Sanitation Program (WSP) has average self-reported monthly income by the household provided technical assistance to local and national govern- head was 114,769 TZS (approximately US$73.00).2 Al- ments implementing large rural sanitation and handwash- though self-reported income is not always a reliable mea- ing promotion programs in various countries.1 In Tanzania, sure and must be interpreted with caution, the income of handwashing with soap and sanitation programs were the household head can serve as a proxy for total household phased into 10 rural districts in the second half of 2009. income. This report presents summary descriptive statistics for key Water Sources demographic, socioeconomic, hygiene, health, and child Water is typically collected by women (94.2% of house- development variables based on a survey of approximately holds in our study). On average, only about half of house- 1,500 households in the Masasi, Musoma rural, Rufiji, holds (49.7%) had access to an improved water source, Iringa rural, and Mpwapwa districts. It offers a glimpse at which generally was not in their dwellings or on their plots. the general status of sanitation and hygiene practices in Drinking water typically came from three main sources: some of the program’s target areas before the beginning of piped water from public tap (24.2%), an unprotected dug implementation activities. well (27.1%), and surface water (19.2%). On average, 31.5% of these water sources were located in the house- The household survey, conducted by Muhimbili University hold’s own yard or plot, 13.4% within the dwelling, and the of Health and Allied Sciences (MUHAS), was carried at rest (55.1%) were located elsewhere, suggesting that most the end of 2008 and early in 2009. The original goal of households are investing time in collecting water. the baseline survey was to validate the design of the impact evaluation of the program. However, unexpected problems The majority of households stored drinking water at home, with data reliability and the enumerators’ training resulted but only 24.4% reportedly treated the water before drink- in data collection being cancelled in five of the 10 districts ing. Of these, less than half (43%) mentioned boiling water that were part of the evaluation. before drinking as a treatment. This suggests that improv- ing water safety practices in these districts could help pre- The statistics presented have been positively validated vent waterborne diseases. against existing household surveys, including the 2010 Tan- zania Demographic and Health Survey (DHS). Handwashing Behavior and Sanitation Handwashing behavior is known to be difficult to assess. Summary of Findings In this study, we relied on two sources: self-reported hand- Characteristics of Targeted Households washing at critical times and, as a proxy measure, spot-check In the targeted areas in rural Tanzania, the typical house- observations of whether the household had a designated hold is headed by a male and comprises five members. Most place for handwashing with both soap and water. An ad- houses are single detached dwellings with mud or brick ditional measure assessed the cleanliness of the caretaker’s walls and clay floors. Households typically use kerosene for hands through direct observation—again to serve as a proxy lighting and wood for cooking, and about half of house- indicator of handwashing with soap behavior. holds own a few animals and a bicycle. Although most caregivers (more than 78%) reported hav- The mean age of household members studied was 18.2, ing used soap to wash hands at least once in the previous and 80% of household members had some schooling. The 24 hours, when asked about the circumstances, only 33.7% 1 2 For more information on Global Scaling Up Rural Sanitation and Handwashing, Approximate conversion rate as of June 2012 was 1,500 Tanzanian shillings (TZS) visit www.wsp.org/scalingupsanitation. to 1 US dollar (USD). www.wsp.org iii Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Executive Summary mentioned handwashing at one or more critical juncture and under two. Most children (72.1%) consumed homemade only 21.2% mentioned handwashing after using the toilet. gruel and one-fifth of the children were given beverages such as tea or coffee (20.3%). With respect to the previ- In terms of sanitation, rural Tanzania mostly relies on basic ous day’s food, 70.3% of the children had received solid or latrines that do not separate humans from excreta and are semi-solid food an average of 2.41 times. described as “fixed-point open defecation.� The most com- mon type of toilet facility reported was a pit latrine, present Conclusion in almost 89% of the studied households. Only 12.7% of The survey revealed that there was limited baseline knowl- households reported having a pit latrine with slab. Open edge of the critical handwashing times among the target defecation was reported in 9.2% of the households. households prior to the program, indicating room to im- prove handwashing behavior. Likewise, the survey indi- Child Care and Nutrition cated limited access to improved water sources, a scarcity Because caregiver characteristics and child care quality of pit latrines with slabs, and a non-negligible percent- can dramatically affect the health, nutritional status, and age of open defecation practice in the studied households. development of young children, the study collected in- Underlying challenges also included unsafe facilities for formation on feeding practices, caregiving behavior, and small children and poor practices related to disposal of caregiver well-being. child feces. In the studied households, most children under the age of The data presented in this technical report provides a snap- two played with household objects (85.9%) and, in more shot of the conditions of the target population prior to the than half of the cases, an adult sang songs with the child. start of the sanitation and handwashing programs. An im- However, in the three days prior to the survey, less than pact evaluation of the programs, which will rely exclusively 15% of caregivers reported reading (13.7%) or telling sto- on post-intervention data, will be carried out during 2012; ries (14.5%) to the child. a full report will be published in 2013. The study hopes to enable a close examination of the links between poor In terms of diet, almost 90% of children had been given sanitation, handwashing behavior, and health, and provide plain water since the previous day and breast milk con- evidence for future projects in rural Tanzania. sumption, as expected, was very high (89%) for children iv Scaling Up Rural Sanitation Contents Executive Summary.................................................................. iii Acronyms ................................................................................. vii I. Introduction ............................................................................... 1 II. Characteristics of Targeted Households .................................. 3 III. Water Sources ........................................................................... 7 IV. Handwashing Behavior ............................................................. 9 V. Sanitation ................................................................................. 11 VI. Child Care Environment .......................................................... 15 VII. Child Health and Anthropometric Measures .......................... 18 VIII. Conclusion ............................................................................... 20 Figures 1: Map of Tanzania Showing 10 Project Districts .................. 1 2: Distribution of Sampled Population by Age Group and Gender (Population Pyramid) ............................................. 4 Tables 1: Summary Statistics ............................................................ 3 2: Percent Distribution of the Basic Socio-Demographic Characteristics.................................. 3 3: Percent Distribution of Households Assets (% HHs) .................................................................. 5 4: Dwelling Characteristics and Materials by Observation................................................................... 5 5: Dwelling Energy Source ..................................................... 6 6: Water Source ..................................................................... 7 7: Drinking Water ................................................................... 8 8: Self-Reported Handwashing Behavior with Soap by District.......................................................... 9 9: Household Main Sanitation Facility Characteristics (% HHs) .................................................. 11 10: Household Main Sanitation Facility Sharing and Safety (% HHs) ............................................ 12 www.wsp.org v Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Contents 11: Other Characteristics of Households’ Sanitary Condition (% HHs) ............................................. 13 12: Child Breastfeeding (Children < 2) ................................... 15 13: Infant/Young Child Feeding (Children < 2) ....................... 16 14: Infant/Young Child Learning Environment (Children < 2) .............................................. 17 15: Anemia Prevalence (% of Children < 2) ........................... 18 16: Nutritional Status of Children < 2..................................... 19 17: Estimates of Z-Scores (in SD) from Selected Datasets ................................................... 19 vi Scaling Up Rural Sanitation Abbreviations and Acronyms ALRI(s) Acute Lower Respiratory Infection(s) ARI(s) Acute Respiratory Infection(s) CLTS Community-Led Total Sanitation DHS Demographic and Health Survey HH Household MUHAS Muhimbili University of Health and Allied Sciences SD(s) Standard Deviation(s) TZS Tanzanian Shilling WHO World Health Organization WSP Water and Sanitation Program www.wsp.org vii I. Introduction Since 2007, the Water and Sanitation Program (WSP) has paper presents findings from the survey carried to assess provided technical assistance to local and national govern- the pre-program conditions of sanitation and handwashing ments implementing large rural sanitation and handwash- in five out of the 10 districts where the program is being ing promotion programs in various countries, under the implemented in Tanzania. The household survey was com- umbrella of two related projects, Global Scaling Up Hand- missioned to the MUHAS. It was carried out between the washing and Global Scaling Up Rural Sanitation.3 The goal end of 2008 and early 2009 in approximately 1,500 house- is to contribute to addressing the poor hygiene and sanita- holds in the districts of Masasi, Musoma rural, Rufiji, Ir- tion conditions of large rural populations in the developing inga rural, and Mpwapwa. The survey intended to serve world. In Tanzania, the handwashing with soap and rural as a baseline to the implementation of the program, but sanitation programs were phased into 10 rural districts in unanticipated problems with reliability of data and enu- the second half of 2009. merators training resulted in the cancelation of data collec- tion in five out of the 10 districts originally planned and Handwashing with soap at critical times (such as after con- the impossibility of using the data in longitudinal analysis tact with feces and before handling food) has been shown as baseline to validate the evaluation randomized design, as to substantially reduce the risk of diarrhea and acute re- it was originally intended. spiratory infections (ARIs). The handwashing project aims to test whether handwashing with soap behavior can be generated FIGURE 1: MAP OF TANZANIA SHOWING 10 PROJECT DISTRICTS and sustained among the poor and vulnerable using innovative pro- UGANDA Lake motional approaches. In a similar KARAGWE Victoria MUSOMA KENYA RWANDA fashion, scaling-up rural sanitation focuses on learning how to com- bine the approaches of commu- BURUNDI nity-led total sanitation (CLTS), IGUNGA behavior change communications, KONDOA and social marketing of sanitation KITETO LEGEND/KEY to generate sanitation demand and Lake PROJECT DISTRICTS* DODOMA NATIONAL CAPITAL Tanganyika strengthen the supply of sanitation INTERNATIONAL MPWAPWA BOUNDARIES products and services at scale, lead- Dar es Salaam DEM. REP. *Based on District boundaries of 2002. OF IRINGA ing to improved health for people 0 50 100 CONGO RUFIJI KILOMETERS in rural areas. SUMBAWANGA INDIAN One of the global project’s objec- OCEAN tives is to learn about and docu- ment the long-term health and ZAMBIA Lake MASASI MALAWI Malawi IBRD 38777 AUGUST 2011 welfare impacts of the country pro- MOZAMBIQUE gram’s interventions. This technical 3 For more information on Global Scaling Up Rural Sanitation and Handwashing, visit www.wsp.org/scalingupsanitation. www.wsp.org 1 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Introduction In spite of difficulties experienced during data collection, as to the general status of sanitation and hygiene practices this technical note presents summary descriptive statistics in the rural areas surveyed and some of the districts where for key demographic, socioeconomic, hygiene, health, and the programs took place, prior to implementation activities. child development variables that were considered the sim- Findings are occasionally cross-tabulated by administrative plest in survey application and compare well with infor- location (districts and corresponding regions) or sanitary mation obtained from other surveys. The figures presented conditions; however, no confident relation should be as- here have been positively validated against existing infor- sumed between these variables based on a simple empirical mation from available household surveys, in particular the association. 2010 DHS. The general aspects presented provide guidance 2 Scaling Up Rural Sanitation II. Characteristics of Targeted Households Table 1 shows a brief summary of household basic socio- outside the home. Finally, self-reported monthly income economic characteristics. The main eligibility criteria used by the household head was 114,769 TZS. Although self- in the survey was that the household had at least one child reported income is not always a reliable measure and has under two years of age, in accordance to the target popula- to be interpreted with caution, income of the head of tion of the program. We found that the average household household could be thought as a proxy for total household comprised 4.9 individuals; among them there were, on av- income. With an average household size of 4.9 members, erage, 2.4 male individuals. Consistent with the household equivalent per capita reported monthly income would be eligibility criteria of having at least one child under two approximately 23,422 TZS. As a reference, reported mean years of age, on average there were 1.4 children younger per capita household monthly income in the 2007 Tanza- than five years old per household; 68% of households inter- nia Mainland Household Budget Survey for rural areas was viewed had exactly one child under five. 28,418 TZS. The mean age of the household members was 18.2 and The following tables provide further analysis of the socio- 80% of household members have had some schooling. Ap- demographic and socio-economic characteristics of the proximately 85% of the 1,586 interviewed households have household. Table 2 presents the distribution of basic house- a male household head. The average age of the household hold demographic variables: age of the household members head is 37.6 years old; approximately 85% have had some level of school attendance and 90.2% reported working TABLE 2: PERCENT DISTRIBUTION OF THE BASIC SOCIO- DEMOGRAPHIC CHARACTERISTICS TABLE 1: SUMMARY STATISTICS Age (% Individuals): Mean 0–4 27.8 Household (HH) size 4.9 5–9 13.6 Number of children under five yrs per HH 1.4 10–14 9.3 at the time of survey, eligible HH only 15–19 7.0 Number of males per HH 2.4 20–24 8.3 HH Head: 25–29 8.8 Male (%) 84.8% 30–34 8.4 Age 37.6 35–39 5.7 Ever attended school (%) 84.8% 40–44 4.0 Worked outside household in last 12 90.2% 45–49 2.5 months, age > 14 (%) 50+ 4.8 Monthly Labor Income (in TZSs) 114,769 Total 100 All HH Members: Percentage of HHs with following # of children under 5: Age 18.2 1 child 68.0 Ever attended school (%) 80.0% 2 children 27.9 Worked outside household in last 12 61.5% 3 or more children 4.1 months, age > 14 (%) Total 100 www.wsp.org 3 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Characteristics of Targeted Households The targeted population is young; on and the total number of children under the age of five per household. The target average, more than 50% of the household population was very young; on average, more than 50% of the household mem- members are under 14 years old. This is bers were under 14 years old. Figure 2 presents the sample population distribu- consistent with figures from rural mainland tion by age group and gender, reflecting compliance with the enrollment criteria. Tanzania. Table 3 shows assets of households and other ownerships. In terms of assets, more than half of the households (54.9%) had a radio or a cassette or CD player. Items associated with more well-off households such as TVs or VCRs were scarce: 2.1% and 1.3% of the households reported having such items. On average, 39.5% of the households had one or more bicycles and 71.6% had mattresses. We also observed that the large majority of the households owned mosquito nets and bed frames, 79.2% and 80.1% respectively.4 Most households possessed some type of farm tools (89.4%) and a little more than half of the households owned animals (52%). The typical household in the program The analysis of the household dwelling type and construction materials is sum- areas of rural Tanzania is headed by a marized in Table 4. Most households (82.5%) allowed enumerators to enter the male and comprises five members living in household to observe dwelling characteristics. Among the observable households, a single detached dwelling with clay floor we found that the most common type of dwelling was a detached, independent and mud or brick walls. FIGURE 2: DISTRIBUTION OF SAMPLED POPULATION BY AGE GROUP AND GENDER (POPULATION PYRAMID) 50+ 45–49 40–44 35–39 30–34 25–29 20–24 15–19 10–14 5–9 0–4 16 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 16 Percentage of population in the sample by age groups Males (%) Females (%) 4 Tanzania has had a successful mosquito net program for the past 10 years; nets are free to all pregnant mothers and children under five years of age, so, it is likely that these household nets were not purchased. 4 Scaling Up Rural Sanitation Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Characteristics of Targeted Households TABLE 3: PERCENT DISTRIBUTION OF TABLE 4: DWELLING CHARACTERISTICS AND MATERIALS HOUSEHOLD ASSETS (% HHs) BY OBSERVATION Bed frame 80.1 HH allows enumerator to observe housing 82.5 Mosquito net 79.2 characteristics (% HHs) Mattress 71.6 Type of Dwelling (% observable HHs): Radio, CD, cassette 54.9 Detached house 43.9 Stove (gas or other) 40.4 Buildings 24.8 Bicycle 39.5 Apartment 6.3 Cell phone 21.6 Multi-family house 5.5 Clothes Iron (charcoal) 10.3 Room in a larger dwelling 0.9 Sewing machine 4.2 Improvised housing unit 0.7 Other house/other buildings 2.2 NA/Missing * 17.9 TV 2.1 TOTAL 100 Motorbike 1.4 Walling Materials (% observable HHs): VCR, DVD 1.3 Unbaked brick, adobe 34.5 Machinery, equipment 0.9 Mud 30.7 Clothes Iron (electric) 0.8 Brick 24.9 Blender 0.8 Other (including tin sheeting, bamboo) 5.5 Automobile or truck 0.3 Wood, logs 2.8 HH owns farm equipment 89.4 Concrete 1.5 HH owns other piece of land besides home 46.8 TOTAL 100 HH has animals 52.0 Roofing Materials (% observable HHs): Number of different livestock owned by HH (average) 0.96 Tin, zinc sheeting 47.9 Other (including canvas, brick, concrete, adobe) 39.5 Bamboo 5.7 Mud 5.2 The average household uses kerosene for Wood, logs 1.8 lighting, wood for cooking, and in about TOTAL 100 half of the cases owns a few animals and Flooring Materials (% observable HHs): a bicycle. Clay, earthen floor 78.8 Concrete 15.1 Other (incl. tile, linoleum, parquet) 6.0 TOTAL 100 www.wsp.org 5 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Characteristics of Targeted Households dwelling (43.9%). The most common construction mate- TABLE 5: DWELLING ENERGY SOURCE rial of walls was unbaked brick (34.5%); followed by mud Dwelling Lighting Source (% HHs): and baked brick (30.7% and 24.9%, respectively). The use Kerosene 86.1 of other walling materials such as concrete or wood was rare. Wood 7.2 Tin or zinc sheeting was the most common type of roofing Electricity 2.3 material (47.9%). In 78.8% of the observable dwellings, Other (incl. peat, candles, battery, solar, charcoal) 2.1 the floor was clay, or earthen floor, and only 15.1% of ob- No Lighting 1.6 servable households had concrete floors. Gas 0.6 The survey also included information regarding the type of Total 100.0 energy source used for lighting and cooking in the dwelling Dwelling Cooking Fuel (% HHs): (see Table 5). For dwelling lighting source, the large major- Wood 91.0 ity of the households (86.1%) used kerosene, with wood Charcoal 5.9 being the second alternative (7.2%). Most of the house- Kerosene 1.8 holds (91%) used wood as the primary cooking fuel, fol- Other (incl. coal, peat) 1.1 lowed by charcoal (5.9%). No Fuel for Cooking 0.2 Total 100.0 6 Scaling Up Rural Sanitation III. Water Sources The pre-program survey also investigated the household season); however, because almost every household had water source and the treatment that household mem- the same water source throughout the year, we present bers apply to drinking water. Questions related to water results for the rainy season only. Results are summarized source were disaggregated by season (rainy versus dry in Tables 6 and 7. TABLE 6: WATER SOURCE TABLE 7: DRINKING WATER JMP defined improved water source (% HHs) 49.7 Stores drinking water in home (% HHs) 86.0 Source of Water for Drinking Use (% HHs): Frequency of washing drinking water storage (% HHs Dug well… that indicated storing drinking water at home): unprotected 27.1 More than once per week 59.8 protected 7.7 Once per week 19.2 Piped water into… Rarely 18.8 public tap, standpipe 24.2 Never wash 2.3 yard, plot, dwelling 1.3 TOTAL 100.0 Surface water 19.2 Cleansing agent used to wash drinking water storage Tube well, worewhole 10.1 (% HHs that indicated washing water storage): Rainwater 5.1 Soap, detergent, bleach 53.4 Spring water… Water only 33.5 unprotected 3.3 Other 10.0 protected 1.4 Mud 2.5 Other sources, water Ash 0.7 Vendor 0.8 TOTAL 100.0 TOTAL 100 Prepares water before drinking (% HHs): Source location (% HHs): No 68.4 Elsewhere 55.1 Yes 24.4 In own yard, plot 31.5 Sometimes 7.2 In own dwelling 13.4 Method of preparing water (% HHs that indicated TOTAL 100 preparing water before drinking)*: Covered source (% HHs): Boil 43.2 Open 64.7 Stand and settle water before drinking 32.3 Covered 30.6 Strain through a cloth 22.9 Other answer 4.8 Filter 7.3 TOTAL 100 Chlorine 5.7 Who mainly collects water in HH (% HHs): Iodine 0.8 Adult woman 94.2 *For HH which answered both Yes and Sometimes. Multiple Adult man 3.2 responses are permitted. Child < 15 years 1.6 Other members 1.1 TOTAL 100 www.wsp.org 7 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Water Sources On average, only about half of households As Table 6 shows, almost half of the households (49.7%) reported having ac- (49.7%) have access to an improved water cess to an improved water source. When taking a narrower look at the data, source, which is generally not in their we find three main sources of drinking water in the surveyed households: piped dwellings or on their plots. water from public tap (24.2%), unprotected dug well (27.1%), and surface water (19.2%). On average, 31.5% of these water sources were located in the household’s own yard or plot, 13.4% within the dwelling, and the rest (55.1%) are located elsewhere, suggesting most of households could be investing some significant amount of time collecting water. Regarding features of the water source, 30.6% of the households used a water source that was covered, while 64.7% reported using uncovered water sources. In the vast majority of the house- holds (94.2%), an adult female was in charge of collecting water from the source. The task was performed by an adult male in only 3.2% of the households and by a child under 15 years old in 1.6% of the households. In rural Tanzania, collecting water is a Finally, we explored practices related to drinking water consumption (Table 7). woman’s task (94.2% of households). The majority of households stored drinking water at home, but only 24.4% re- ported treating the water before drinking it. Of these, less than half (43%) men- tioned boiling the water as one of the treatments. This suggests that water safety practices could be considerably improved in these districts in order to prevent waterborne diseases. 8 Scaling Up Rural Sanitation IV. Handwashing Behavior Handwashing with soap at critical times (such as after contact with feces and before handling food) has been shown to substantially reduce the risk of diarrhea. Children under five years of age represent the age group most susceptible to diar- rheal disease and acute lower respiratory infections (ALRIs), two major causes of childhood morbidity and mortality in less developed countries. These infections, usually transferred from dirty hands to food or water sources or to the mouth directly through hand-to-mouth contact, can be prevented if mothers/caregivers wash their hands with soap at critical times such as before feeding a child, cook- ing or eating, and after using a toilet or having contact with a child’s feces. In this analysis, these are considered as critical junctures. Handwashing behavior is difficult to assess. In this study, we relied on two sources: self-reported handwashing at critical times and, as a proxy measure, spot-check observations of whether the household had a designated place for handwashing with both soap and water available. An additional measure assessed the cleanli- ness of the caretaker’s hands through direct observation, which is another proxy indicator of handwashing with soap behavior. Most caregivers reported using soap to wash their hands at least once in the previous 24 hours, but when asked the In the rural Tanzanian areas surveyed, a majority of the caregivers—more than circumstance in which they last washed, 78%—reported having used soap to wash hands at least once in the previous 24 only 33.7% mentioned a critical time and hours. However, when asked under what circumstances they last used soap to only 21.2% mentioned after using the wash hands, only 33.7% mentioned at least one of the critical times (see Table 8). toilet. TABLE 8: CAREGIVERS SELF-REPORTED HANDWASHING BEHAVIOR WITH SOAP BY DISTRICT (% PREVIOUS 24 HOURS) DISTRICT (REGION) Iringa Masasi Mpwapwa Musoma Rufiji (Iringa) (Mtwara) (Dodoma) (Mara) (Pwani) TOTAL Washed hands with soap at least once during the following events During at least one critical juncture 34.0 35.9 37.4 27.1 36.3 33.7 Using the toilet 22.7 15.1 30.1 13.7 24.7 21.2 Cooking or preparing food 13.6 17.6 12.2 11.4 10.1 12.5 Feeding children 9.1 19.5 11.3 5.3 7.5 9.7 Cleaning children’s bottom 11.6 7.3 13.5 6.7 6.4 9.1 Washed hands with soap at least once in previous 24 hours 86.9 78.0 83.1 72.6 76.0 78.5 www.wsp.org 9 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Handwashing Behavior Only 21.2% mentioned “using the toilet� among the occasions in which they had used soap to wash hands since the previous day, and only 9.1% mentioned “clean- ing children’s bottom.� In relation to the other critical times, 12.5% of caregivers reported that they had washed hands with soap at times of cooking or food prepa- ration, and 9.7% of caregivers mentioned when feeding a child. On average, self-reported handwashing with soap was relatively higher among wealthier than poorer households for most critical junctures. Table 8 also shows disaggregation by districts and regions. Among all districts, there were slight differences, show- ing Mara with the lowest rates of handwashing and Dodoma with the highest. However, when inspecting wealth and regional breakdowns there were no clear patterns; population in these rural districts seemed fairly homogenous. 10 Scaling Up Rural Sanitation V. Sanitation Although sanitation coverage in Tanzania is relatively high since a “latrinisation� program was introduced by the government in the early 1970s,5 most of rural Tanzania still relies on basic latrines, which do not separate humans from excreta and are described as “fixed-point open defecation.� Over the years, many of those basic latrines lacked adequate maintenance or fell into disrepair. In this section, we investigate the most common sanitation facilities available in the households surveyed, and some of their features. Table 9 presents the different types of sanitation facilities reported. Unfortunately, The most common type of toilet facility there were ex-post reports of problems with the interpretation that enumera- was a pit latrine, present in almost 89% of households. Only 12.7% of households tors gave to the type of facilities, in particular the flush to pit latrine classifica- reported having a pit latrine with slab. tion, which apparently was understood as any latrine with water present by the Open defecation was reported in 9.2% of side. However, the presence of water likely was used as a method of anal cleans- households. ing, rather than for flushing. Taking this caveat into consideration, we could no longer use the original classification and thus grouped pit latrines of any type. Pit latrines thus reached 89% predominance from adding the 35.6% of house- holds that reported having a pit latrine without slab or open pit, the 39.6% that TABLE 9: HOUSEHOLD MAIN SANITATION FACILITY CHARACTERISTICS (% HHs) HH Main Sanitation Facility: Pit latrine… 88.9 with flush (water present) 39.6 without slab, open pit 35.6 with slab 12.7 ventilated improved 1.1 Open defecation 9.2 Flush other (piped sewer system, septic tank or elsewhere) 0.9 Composting toilet 0.4 Other (e.g. bucket, hanging toilet) 0.4 Total 100 Location of Main Sanitation Facility: In household yard 81.1 Less than 10 min walk from the household 10.9 Other 5.4 Household 1.5 Inside household 1.0 TOTAL 100 5 World Bank, 1996. www.wsp.org 11 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Sanitation Most facilities were located in the reported having a latrine with what can be understood as flush-water present by household’s yard (81.1%). There was the side, the 1.1% that reported having a ventilated improved pit latrine, and the no apparent gender bias in the use of mere 12.7% of households that reported having a pit latrine with slab. facilities; men and women reportedly shared them in 96.7% of households interviewed. These numbers seem consistent with the 2010 DHS survey for rural mainland, which found that 71.4% of households used a pit latrine without slab or open pit, while 6.3% of households used a pit latrine with slab. Open defecation was reported in 9.2% of the households, while for rural mainland, the DHS reported 17.8% of open defecation (no facility/bush/field). Regarding location, most of the sanitation facilities were located in the household yard (81.1%) and another 10.9% were located within a 10-minute walk from the dwelling. We present findings about household main sanitation facility safety and sharing in Table 10. A large majority of the sanitation facilities were not shared with other households in the neighborhood (86.2%) and were reported as private (89.9%). Of those reportedly sharing (13.8%), in most cases they shared with two or three TABLE 10: HOUSEHOLD MAIN SANITATION FACILITY SHARING AND SAFETY (% HHs) Sanitation facility in HH is… not exclusive for men or women 96.7 private 89.9 not shared with other HHs in the neighborhood 86.2 shared with other HHs: 13.8 1 other HH (% of shared HHs) 5.5 2 other HHs (% of shared HHs) 46.1 3 other HHs (% of shared HHs) 18.0 3+ other HHs (% of shared HHs) 30.4 Average number of people sharing the toilet 5.94 Women in HH feel that sanitation facility… is safe to use during day time 87.8 is safe to use during night 82.0 provides enough privacy during defecation 75.5 HH most knowledgeable member reports children < 5 not feeling safe using sanitation facility 51.3 With the main sanitation facility, the HH is… somewhat satisfied 29.6 very satisfied 26.7 less than satisfied 23.5 completely dissatisfied 19.6 12 Scaling Up Rural Sanitation Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Sanitation other households. In addition, there was no apparent gender bias in the use of Notably, 51.3% of respondents (most facilities; men and women reportedly shared them in 96.7% of households in- knowledgeable household member) terviewed. The DHS for rural mainland found 80.2% of households not sharing reported not feeling that facilities were safe for children under 5 years old. facilities and 12.6% sharing with another household. In addition, we explored feelings of safety and privacy for female household members, and they generally responded positively: 82% felt it was safe to use the facility at night and more than 87% felt safe using it during the day, while more than 75% reportedly felt they had privacy during defecation. Notably, 51.3% of respondents (the most knowledgeable household member) reported that they did not feel the facilities were safe for children under five years of age. Finally, when asked about satisfaction with the sanitary facility, 19.6% of households declared complete dissatisfaction. Table 11 reports other aspects of household sanitary conditions and practices. In 36.2% of households, flies were reported as always present near the sanitation TABLE 11: OTHER CHARACTERISTICS OF HOUSEHOLDS’ SANITARY CONDITION (% HHs) Flies at/near place for defecation… always 36.2 sometimes 51.7 rarely 11.9 Visible Feces in/around HH: None 72.8 1 to 5 feces 20.2 5 to 10 feces 4.1 More than 10 feces 2.9 TOTAL 100.0 Disposal of Child Feces: Single response 96.2 Toilet, latrine (% of single response) 79.4 Open disposal incl. bushes, ground, drain (% of single response) 19.5 Garbage (% of single response) 1.0 Other (% of single response) 0.1 TOTAL 100.0 Multiple reponses* 3.8 *Multiple entries are allowed for this question. www.wsp.org 13 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Sanitation facility. Flies can act as vectors of transmission, and some studies have associated them with certain diarrhea-causing pathogens. When handling children’s feces, most Finally, we asked about the presence of visible feces, as they are the most common households relied on disposal to the source of diarrhea pathogens in the environment. In most cases in this survey, latrine or sanitation facility (almost 80%); no visible animal or human feces were observed inside or around the household however, a considerable proportion (72.8%). However, in 20.2% of the households, one to five pieces of feces were reported that they were disposed of in the open (19.5%). visible. Unsafe disposal of children’s feces has increasingly gained attention as a factor associated with diarrhea risk. In this survey, most households reported a consistent practice surrounding child feces disposal (over 96% chose a unique method of disposal). Among these, most households relied on disposal in the latrine or sanitation facility (almost 80%), but a considerable proportion reported that child feces were disposed of in the open (19.5%). 14 Scaling Up Rural Sanitation VI. Child Care Environment It is largely recognized that characteristics of the caregiver and the quality of care a child receives have huge impacts on young children’s health, nutritional status, and development beyond variation due to socio-economic and education vari- ables. We collected information on feeding practices, caregiving behavior, and caregiver well-being in order to more carefully tease out the potential effects of the behavior change interventions on child health and development. Table 12 summarizes breastfeeding habits within the interviewed households. The average breastfeeding duration was 15 months, and 93% of the children received colostrum6 during the first three days after childbirth. Only 15.7% of the mothers fed their babies liquids other than colostrum or breast milk during the first three days of life. Of those children who were fed other liquid, more than two-thirds were provided with plain water. TABLE 12: CHILD BREASTFEEDING (CHILDREN < 2) Child ever breastfed at the time of survey (% children < 2) 98.4 Still breastfeeding (% children ever breastfed) 87.9 Average months of breastfeeding (for children ever breastfed) 15.0 During the first three days after birth, …. colostrum was fed (% children < 2) 93.0 liquid other than colostrum or breast milk was fed (% children < 2) 15.7 Single Response 87.0 Plain water 60.6 Sugar-salt solution 10.8 Milk other than breast 7.5 Other liquids 7.4 Sugar, glucose water 5.0 Tea or gripe water 4.6 Instant formula 4.1 Multiple Responses 13.0 6 Colostrum is produced prior to mature breast milk during pregnancy and through the first 3–6 days of life. It contains not only necessary nutrients but also properties that help protect the baby from viral and bacterial infections. www.wsp.org 15 Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Child Care Environment The survey also included a section on children’s diet, summarized in Table 13. Specifically, caregivers of infants under the age of two were asked about liquids and food given to their children in the day previous to the interview. Almost 90% of the children were given plain water since the previous day; breast milk consumption (89%) was very high as expected for children under the age of two. Homemade gruel was also consumed by a majority of children (72.1%). Interest- ingly, one-fifth of the children were given tea or coffee (20.3%). With respect to TABLE 13: INFANT/YOUNG CHILD FEEDING (CHILDREN < 2) Liquids given the day before survey taken (% children): Plain water 89.5 Breast milk 89.0 Homemade porridge or gruel 72.1 Caffeine beverages 20.3 Fortified child food 8.1 Fruit juice 6.1 Other milks or instant formula 3.2 % of children that were given solid or semi-solid food the day before survey taken 70.3 Food given (% children who had solid or semisolid food the day before): Cereal, rice, other grain-based food 94.7 Other fruits, vegetables 89.9 Beans, peas, lentils 86.2 Fruits or vegetables rich in vitamin A (carrots, yams, mango, papaya, green leaf vegetables) 82.4 Meat red, white 80.3 Potatoes, yucca, other roots 73.9 Oil, fats, butter 48.9 Average number of times solid or semi-solid food was given the day before survey taken 2.41 1 meal 15.8 2 meals 38.6 3 meals 37.2 3+ meals 8.4 Feed themselves with utensils or hands (% children who had solid or semi-solid food the day before) 68.6 Received vitamin A supplement in the last 6 months (% children < 2) 56.4 Given iron pills or syrup in the last seven days before survey taken (% children < 2) 25.1 16 Scaling Up Rural Sanitation Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Child Care Environment food given the day before, 70.3% of the children received solid or semi-solid food Most children under the age of two 2.41 times on average. When asked about dietary supplements, 25.1% of caregiv- are breast-fed (89%) and play with ers declared giving iron pills or syrup to their children in the seven days prior to household objects (85.9%). In more than 50% of cases, adults sing songs with the survey and 56.4% mentioned having provided vitamin A supplement to their their children. Caregivers reported rarely children at least once in the previous six months. A large number of caregivers reading books (13.7%) or telling stories to (68.6%) also mentioned that children who had been given solid or semi-solid the child (14.5%) in the three days prior to food the day before had also fed themselves. the survey. Furthermore, there were specific questions related to household support for learning and development, including the frequency with which adults engaged children in various activities recognized as promoting language and cognitive de- velopment. Table 14 shows that 85.9% of the children under the age of two played with household objects, and in more than 50% of cases, adults had sung songs with their children. Only 2.4% of the children had attended an early education program. Although most respondents reportedly took their children outside the home in the three days prior to the survey (71.5%), a low number of caregivers reported reading books (13.7%) or telling stories to their children (14.5%) in the same period. TABLE 14: INFANT/YOUNG CHILDREN LEARNING ENVIRONMENT (CHILDREN < 2) Child plays with household objects (% children) 85.9 Adult take child outside home (% caregivers associated with children < 2) 71.5 Adult sings songs with child (% caregivers associated with children < 2) 50.1 Adult spend time naming, counting, drawing with child (% caregivers associated with children < 2) 23.8 Adult tells stories to child (% caregivers associated with children < 2) 14.5 Adult reads books with child (% caregivers associated with children < 2) 13.7 Child attended early education programs (% children) 2.4 www.wsp.org 17 VII. Child Health and Anthropometric Measures The survey also intended to provide information on anemia Diarrhea was defined as the reported presence of three or prevalence, children’s diarrhea prevalence, ALRI, and other more loose or watery stools over a 24-hour period or one or health symptoms; child development; and child growth in more stools with blood and/or mucus present, using symp- order to generate evidence on the association with sanita- tom data reported from caregivers. Acute lower respiratory tion and hygiene interventions. However, validation of the infection was defined using the clinical case definition of symptom-related data and nutritional indexes against infor- the World Health Organization (WHO 2005), which di- mation from other surveys suggested measurement prob- agnoses a child as having an ALRI when he/she presents lems during data collection. In light of this, results are not constant cough or difficulty breathing and raised respira- reported in detail. tory rate symptoms, as reported by the caregiver. Presence of anemia was measured by hemoglobin concen- Whereas estimates from the 2010 DHS reported prevalence tration in children between six months and two years of age of diarrhea among children under five at 14.6% in main- (<110g/L per international standards), and findings are sum- land, 13.6% in mainland rural areas, and approximately marized in Table 15. The majority (79.3%) of samples taken 20% for children under 24 months old, the findings in re- indicated the presence of anemia. Estimates from the 2010 lation to caregiver-reported diarrhea for our sample of chil- DHS reported 58.1% prevalence of anemia in rural main- dren under two was below 2.0% (between 19 and 30 cases land and between 68.7% and 81.1% for children between reported out of a total of 2,164 children under two years six months and two years of age, which seemed consistent old). Similarly, caregiver-reported two-day and seven-day with the levels reported in our sample. There were no major ALRI prevalence was positive only in eight and nine cases in differences for households with improved water source the sample, respectively (approximately 1,500 households), (78.4%) or unimproved water source (80.5%). Regarding while the 2010 DHS survey reported 4.7% prevalence of different levels by districts, the percentage of anemia preva- ARI for children under 24 months old.7 The inconsistency lence is highest among children living in Pwani (88.9%) and suggests serious under-reporting in the sample and doubts lowest among children living in Dodoma (71.6%). about reliability of data symptom collected. In light of this, results are not presented in detail here. TABLE 15: ANEMIA PREVALENCE (% OF CHILDREN < 2) (Hb < 110 g/L) The survey also intended to include baseline anthropo- District (Region): metric measures of children under the age of two, such as Rufiji (Pwani) 88.9 weight, height, and arm and head circumference. This in- Masasi (Mtwara) 83.7 formation is important in order to assess the average growth and development of the children. To analyze the child growth Iringa (Iringa) 80.3 findings, anthropometric Z-scores were assigned by compar- Musoma (Mara) 72.8 ing children in the sample to the WHO reference population Mpwapwa (Dodoma) 71.6 median and standard deviation (SD) for each of the afore- Sanitary Conditions: mentioned variables.8 The reference population is designed Improved sanitation 82.1 to be internationally applicable regardless of ethnicity, socio- Unimproved sanitation 76.0 economic status, or feeding practices. The Z-score for each Improved water source 78.4 measure indicates the number of SD units from the median Unimproved water source 80.5 Place for handwashing w/ soap and water 81.3 7 In the DHS, “the prevalence of symptoms of ARI was estimated by asking mothers No place for handwashing w/ soap and water 79.2 whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing in the two weeks preceding the survey.� (DHS, 2010) Overall 79.3 8 World Health Organization, 2005 and 2006. Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Child Health and Anthropometric Measures of the reference population. The WHO guidelines for child For example, the mean height-for-age Z-score was –3.56, growth use a Z-score cutoff of less than –2 SDs below the me- a relatively large number indicating generalized stunting; dian of the reference population for low growth levels (stunted, this figure was higher than the rural mean Z-score of –1.8 wasted, and underweight) and less than –3 SDs from the me- reported in the 2010 DHS and other comparable datasets. dian, indicating severity of the condition (severely stunted, When trimming down the height-for-age to levels feasible wasted, and underweight). In addition, children with a weight- by WHO standards (between –6 to +6), near 20% of the for-height index of more than 2 SDs above the median refer- sample was lost. After trimming, the mean height-for-age ence population are considered obese. Z-score became –2.38, which could be plausible. However, high variability of height-for-age Z-scores (not shown here) Table 16 presents information on children’s nutritional sta- relative to other countries also suggested poor quality mea- tus based on the indexes. Unfortunately, these suggest low surements. Finally, the finding of 9.1% of children report- quality of measurements during data collection as well. edly overweight was unlikely in comparison with the 0.6% reported in the DHS for rural mainland. Similarly, the Validation of these figures against comparable datasets posed weight-for-height mean Z-score was positive, which was doubts about their reliability (Table 17). In our sample, an inconsistent with the other indexes and similar datasets. In average of 58.3% of children were stunted and 35.1% were light of these apparent inconsistencies and the problems ex- severely stunted (height-for-age Z-score); 2.2% were wasted perienced during data collection, we abstain from reporting or malnourished and 0.4% were severely wasted (weight-for- more detailed figures here. height Z-score); and 10.6% were underweight and 2.7% were severely underweight (weight-for-age Z-score). TABLE 16: NUTRITIONAL STATUS OF CHILDREN < 2 Height-for-age Weight-for-height Weight-for-age Background Percentage Percentage Mean Percentage Percentage Percentage Mean Z– Percentage Percentage Percentage Mean Z– below –3 SD below –2 SD Z-score (SD) below –3 SD below –2 SD over +2 SD score (SD) below –3 SD below –2 SD over +2 SD score (SD) characteristics DHS 2010, 17.8 44.7 –1.80 1.2 4.6 4.9 0.00 4.1 16.7 0.6 –1.00 rural mainland * WSP, 5 districts 35.1 58.3 –2.38 0.4 2.2 38.7 1.05 2.7 10.6 9.1 –0.38 *Source: 2010 Tanzania Demographic and Health Survey (DHS) TABLE 17: ESTIMATES OF Z-SCORES (IN SD) FROM SELECTED DATASETS Height-for-age Weight-for-height Weight-for-age Dataset mean Z-score (SD) mean Z-score (SD) mean Z-score (SD) WSP Tanzania, five districts –2.38 1.05 –0.38 Tanzania DHS, 2010 (rural mainland) –1.8 0.0 –1.0 WSP Senegal –0.55 –0.48 –0.67 WSP Himachal Pradesh, India –1.28 –0.58 –1.21 WSP Madhya Pradesh, India –1.92 –1.08 –2.18 Rural Water Project Kenya –1.85 na na Tamil Nadu, India –1.98 na na WSP Peru –1.13 0.46 –0.28 WSP East Java, Indonesia –0.88 –0.43 –0.78 www.wsp.org 19 VIII. Conclusion The findings presented in this technical report provide a Limited baseline knowledge of the critical times for wash- snapshot of the target population before the rural sanita- ing hands indicated that there was scope for improving tion and handwashing behavior change programs started. handwashing behavior in the target population. Likewise, The report explores their household demographics, there was limited access to improved water sources, a scar- socio-economic situation, caretaker’s handwashing behav- city of pit latrines with slabs, and reports of open defecation ior, water sources and sanitation facilities, and key child in a non-negligible proportion of households. Underlying health and growth measures. Due to problems during data challenges also included unsafe facilities for little children collection, figures required validation against information and poor practices related to disposal of child feces. from other surveys. As a result, we reported only summary descriptive statistics for variables that were considered the The impact evaluation planned will rely exclusively on post- simplest in survey administration and that compare well intervention data given the problems experienced during with information obtained from other surveys, in partic- baseline data collection. The survey will be carried out dur- ular the 2010 DHS. Symptom reporting and anthropo- ing 2012 and the full report will be published during 2013. metric measures seemed particularly affected by quality The study hopes to enable a close examination of the links problems in data collection. between poor sanitation, handwashing behavior, and health, and to provide evidence for future projects in rural Tanzania. Scaling Up Handwashing and Rural Sanitation: Findings from a Baseline Survey in Tanzania Conclusion References D. de Waal (2005) National Water Sector Assessment, Tan- World Health Organization (2005) Pocket Book of Hospi- zania. WaterAid. https://www.wateraid.org/other/ tal Care for Children: Guidelines for the Management startdownload.asp?DocumentID=142&mode of Common Illnesses with Limited Resources. Geneva. =plugin. WHO Press. National Bureau of Statistics (NBS) Tanzania and ICF World Health Organization (2006) WHO Child Growth Macro (2011) Tanzania Demographic and Health Standards: Length/Height-for-Age, Weight-for-Age, Survey 2010, NBS and ICF Macro. Weight-for-Length, Weight-for-Height and Body Mass World Bank (1996) Tanzania: Social Sector Review. Re- Index-for-Age: Methods and Development. Geneva. port No. 14039-TA. The World Bank. Washing- WHO Press. ton, D.C. Y. Coombes and N. Paynter (2010) Scaling Up Handwashing World Health Organization/UNICEF Joint Monitor- Tanzania: A Handwashing Behavior Change Journey. ing Programme for Water Supply and Sanita- The World Bank Water and Sanitation Program. tion Website. http://www.wssinfo.org/definitions/ Washington, D.C. infrastructure.html. www.wsp.org 21