UNICEF Eritrea National ODF Sustainability Assessment 2015
Contents Executive Summary... iii Recommendations... iv Abbreviations-Acronyms... v 1. INTRODUCTION... 1 1.1 Historical Background... 1 1.2 Background to CLTS in Eritrea... 1 1.3 Current (Environmental Health) Sanitation and Hygiene Services in Eritrea... 2 1.4 Rationale for the Assessment... 3 1.5 Objectives of CLTS Sustainability Assessment... 3 1.6 Limitations of the Assessment... 3 1.7 Organisation of the report... 3 2. APPROACH AND METHODOLOGY... 5 2.1 Introduction... 5 2.2 Study Area... 5 2.3 Study Design... 5 2.4 Sample Selection... 6 2.5 Target Population and Sampling Frame... 6 2.6 Sample Size Determination... 7 2.7 Procedure for Selecting Sample Villages... 7 2.8 Selection of Sample Households at the Second Stage... 7 2.9 Implementation Phases... 8 2.10 Assessment Instruments... 9 2.11 Selection and Training of Enumerators and Supervisors.... 10 3. FINDINGS OF THE ASSESSMENT... 11 3.1 Classification of the Respondents... 11 3.2 Distribution of Respondents by Zoba... 11 3.3 Sex of Respondents and Household Heads... 12 3.4 Demographic Profile of Selected Households... 13 3.5 Family Size... 14 3.6 Household Structure... 14 3.7 Marital Status of Heads of Households... 16 3.8 Religious Affiliation... 17 3.9 Ethnic Groups... 17 3.10 Educational Level of Heads of Households... 18 3.11 Occupation of Head of Household... 19 3.12 House Ownership... 20 3.13 House Structure... 20 3.14 Type of Wall and Roof Structure... 21 3.15 Type of Floor... 21 3.16 Amenities Source of Energy and Water... 22 3.17 Asset Ownership... 23 3.18 Ranking of Last Year s Estimated Expenditures... 24 3.19 Community Knowledge and Participation in CLTS Triggering... 24 3.20 Child Participation in CLTS... 25 3.21 Use of CLTS Tools... 27 3.22 Promises Made by Participants at the Triggering Sessions... 28 3.23 Identification of Health Promoters... 29 3.24 Social Support... 30 3.25 Regulation to Stop Open Defecation... 32 i
3.26 Latrine Ownership by Zoba... 33 3.27 Number of ODF Villages 2008-2014... 35 3.28 Motivating Factors for Household to Remain ODF... 35 4. Water Sanitation and Hygiene... 37 4.1 Source of Water for Domestic Use... 37 4.2 Time Spent Collecting Water... 38 4.3 Household Daily Water Consumption... 40 4.4 Mode of Payment for Water... 40 4.5 Cost of Water... 40 4.6 General Defecation Practices... 41 4.7 Children... 43 4.8 Disposal of Infant s Feces... 44 4.9 Latrine Ownership, Utilization and Knowledge... 44 4.10 Consequences of not using a Latrine... 46 4.11 Community Action on OD... 46 4.12 Latrine Coverage... 47 4.13 Sources of Latrine Construction Materials... 51 4.14 Repair, Maintenance and Upgrading... 52 4.15 Latrines Sharing... 59 4.16 Cleanliness... 60 4.17 Frequency of Cleaning... 60 4.18 Hygiene Practices in Selected Households... 62 4.19 Latrine Perceptions... 65 4.20 Media and Communication... 68 4.21 Hygiene Information Content... 69 4.22 Latrine Observations... 70 5 Conclusions & Recommendations... 72 5.1 Conclusions... 72 5.2 Recommendations... 72 References... 73 ii
Executive Summary The Government of The State of Eritrea (GoSE) adopted Community-Led Total Sanitation (CLTS) in 2007 incorporating the approach in the national Rural Sanitation Policy 1. The GoSE uses the Community Led Total Sanitation (CLTS) approach to address the issue of rural sanitation in Eritrea. CLTS uses participatory approaches to raise the community s awareness of their sanitation problems and empowers them to make their own decisions about how to address them. The main step in the process is Triggering of the community where during a meeting of the whole community and through various participatory approaches such as mapping, transect walks etc. the community begin to understand the linkages between open defecation and disease. The key point of the CLTS approach is that it uses shock and disgust to drive home the messages and is proving to be a very effective tool globally in breaking down the taboos around discussion and action on open defecation. Following on from the Triggering process, providing the process has been successful in raising awareness and gaining community agreement, the community devise their own Action Plan to address the practice of open defecation in their community. There are no subsidies, materials or latrine designs provided instead the community work themselves to construct their own latrines. Once every household in the community has access to a latrine and there is no longer any open defecation in the village the community will declare themselves Open Defecation Free (ODF). This status will be confirmed by inspection by Public Health Officers. Once confirmed the Community is certified ODF during a celebratory ceremony and erects a sign declaring their ODF status. Eritrea, since adopting the CLTS approach, has made very positive progress towards achieving Open Defecation Free (ODF) status. From a very low baseline, with over 90% of the rural population having no access to a toilet and using the bush for defecation in 2010 2, a total of 688 villages in Eritrea have been declared ODF since the CLTS approach was adopted in 2007. This represents almost 700,000 people, over 30% of the rural population of Eritrea, having gained access to basic sanitation. Despite Eritrea s commitment to addressing the challenge of rural sanitation the country made little or no progress towards achieving its MDG sanitation target of 54% coverage according to the Joint Monitoring Programme report. 3 This may be a reflection of the availability of Government sanctioned, real time data which has tended to lag behind the reality of the sanitation status of rural communities. Maintaining ODF status is the major priority since slipping back to unsafe open defecation is a distinct possibility within ODF communities. Community Health Promoters are trained and mobilised to support the Community with additional support from MoH Public Health Workers The objective of the this assessment was to quantify the sustainability of the ODF status of communities by assessing actual latrine coverage and use one year or more after the community had been certified ODF. The study also aimed at identifying those factors which discourage households and communities from maintaining their ODF status and allow a return to 1 Rural Sanitation Policy & Strategy Directions For Eritrea, MoH, Environmental Health Unit, August 2007 2 EPHS 2010 32015 MDG Update & Assessment WHO/UNICEF Joint Monitoring Programme 2015 iii
the practice of open defecation. To achieve this, an assessment of 1,580 households within 113 ODF certified communities across the six Zobas (regions) of Eritrea was conducted jointly by the Ministry of Health and UNICEF during April-May 2015. The ODF sustainability assessment has shown that whilst the CLTS programme in Eritrea moves forward there is a need to ensure that sustainability of ODF achievements are maintained. The number of community members who have reverted to open defecation despite the high levels of access to newly constructed latrines would indicate that levels of hygiene awareness need to be raised further and that factors identified which facilitate slippage back to open defecation need to be addressed. This would include for example, greater participation in the initial CLTS triggering process, especially for children. Other factors identified included the high cost of construction materials to repair collapsed latrines or upgrade basic latrines, levels of awareness of sanitation and hygiene issues, support visits by hygiene promoters and follow up support from Zoba level Ministry of Health Officers. After ODF declaration, there should be follow up with the village to enforce the community sanctions and in creating a new social norm against open defecation. In addition the capacity of the Community Hygiene Promoters, who as part of the CLTS programme have been mobilised and trained to support communities to maintain their ODF status, plays a large part in a community s ability to sustain their ODF status. Since all of the 1,580 communities included in the assessment had previously declared and been certified as ODF this reversion to open defecation indicates that work still needs to be done to ensure the sustainability of a community s ODF status and prevent slippage back to open defecation practices. This assessment has for the first time quantified the status of ODF communities in Eritrea. The findings have identified areas of the programme to be strengthened in order to improve the longer term sustainability of ODF communities, and provide the evidence base for future development of the CLTS programme to achieve and maintain ODF status with the associated positive health and social impacts. Recommendations Based on the analysis of the findings of the assessment the following key recommendations are made: 1. Improve the quality of CLTS Triggering activities and use of participatory tools. 2. Standardise trainings and CLTS processes for facilitators. 3. Increase proportion of community members participating in triggering activities with a focus on child participation. 4. Review role and contribution of Community Health Promoter s in supporting CLTS intervention. 5. Ensure hygiene messages at local and national level are coordinated with media and communication findings on information sources at community level. 6. Strengthened MoH capacity for monitoring and reporting of the CLTS programme at national and community levels. 7. Strengthen MoH capacity for knowledge management of CLTS programme. 8. Advocate for development of national CLTS Strategic Action Plan and targets for national ODF achievement. 9. Strengthen institutional CLTS i.e. schools and health centres. 10. Prioritise creation of social norm for against OD in communities. iv
Abbreviations-Acronyms CLTS CSPRO DHS EDHS EHD EPLF FGD GIS GoSE GPS IDK KII LSS MoH NGO NL NRS OD ODF PHAST PPS PRA RS SI SPSS SRS TOR UNICEF WASH Community Led Total Sanitation Census and Survey Processing System Demographic Health Survey Eritrea Demographic and Health Survey Environmental Health Division Eritrean People s Liberation Front Focus Group Discussion Geographic Information System Government of the State of Eritrea Geographic Positioning System I Don t Know Key Informant Interview Linear Systematic Sampling Ministry of Health Non-Governmental Organization Natural Leader Northern Red Sea Open Defecation Open Defecation Free Participatory Hygiene and Sanitation Transformation Probability Proportional to Size Participatory Rural Appraisal Random Start Sampling Interval Statistical Package for Social Science Southern Red Sea Terms of Reference United Nations Children s Fund Water, Sanitation & Hygiene v
1. INTRODUCTION 1.1 Historical Background The vast majority of people in rural Eritrea practice open defecation, that is relieving themselves anywhere on the ground in the open. This may be due to a limited awareness of safe hygienic practices coupled with the availability of ample open space around their homesteads and villages. This historically has been the traditional norm in rural Eritrea. It was during the Italian colonial administration from the late 1800s that the legal requirement for building houses fitted with sanitary facilities came into force predominantly in urban areas where the majority of the Italian settler communities resided. There was limited effort to introduce legal instruments enforcing the building of latrines beyond the urban areas and into the rural areas. The Eritrean rural population have continued to defecate and urinate in the open for generations. 1.2 Background to CLTS in Eritrea During the first few years following independence in 1993, the Ministry of Health s (MoH) priority was to re-establish and extend to all citizens irrespective of where they reside, the health services that were previously confined to towns controlled by the Ethiopian garrisons during the period of occupation. Hence, the GOSE, through the MoH launched the Primary Health Care Policy and Policy Guidelines (1998); where among others, 15 objectives for the Environmental Health Services were identified. Under programme strategy, the policy document identified sanitation, safe water supply, solid waste management, health aspects of housing, human resource development, and collaboration among and between all stakeholders as top priorities. In general, there are a number of approaches for addressing community sanitation and hygiene problems. These approaches include: the traditional Subsidy Based Solution; Participatory Hygiene and Sanitation Transformation (PHAST); Participatory Rural Appraisal (PRA); and Community Led Total Sanitation (CLTS). Eritrea has tried several of these approaches to improve rural sanitation and hygiene, including the subsidised latrine building approach which is based on the assumption that people are not building latrines because they are poor and must therefore be supported with subsidies. This approach primarily undermines people s ability to do things by themselves with whatever meager means they have. As a result, subsidised latrine building and hygiene education were not leading to sustained behavior change. On the contrary, the subsidy approach encouraged dependency on outside support, including people who had the capacity and ability to build their own latrines. Following several years of experimenting with the subsidy based approach the government and some NGO s adopted the CLTS approach as the most appropriate to improve the country s rural sanitation situation. To this end, the Government of Eritrea formulated the Rural Sanitation Policy and Strategy Directions for Eritrea (2007). In this policy document, the vision of the nation is articulated as the rural population in Eritrea living in a healthy environment resulting from communities free of Open Defecation, with all people washing their hands and faces, with their food hygienically protected, water hygienically handled, and a clean home environment. The scope of the Rural Sanitation Policy covers all rural villages and local institutions which includes private households, educational institutions, health facilities, religious institutions and commercial entities. The Rural Sanitation Policy is based on a set of key principles that includes coordination and harmonisation, universal access, equity, gender balance, participation and
mobilisation, community based, demand driven, financial and social relevance, environmental sustainability and self-reliance. The policy explicitly states that the CLTS approach will be applied to achieve the five key areas namely: Water handling and use; Latrine coverage and use; Hand washing; Food hygiene; and Cleanliness of the home environment. 1.3 Current (Environmental Health) Sanitation and Hygiene Services in Eritrea In accordance to the Rural Sanitation Policy, CLTS is being implemented throughout rural Eritrea, after abandoning the subsidy based solution approach. CLTS advocates for a hygiene promotion approach where households construct their own latrines using locally available materials. The main idea behind CLTS is similar to the principle of Self-reliance which encourages people to do what they can with whatever means they have at their disposal instead of idly waiting for outside help. In Eritrea, the concept of self-reliance is not new; it was heavily advocated and practiced by the Eritrean People s Liberation Front (EPLF) during the entire 30 years of liberation war. The government of Eritrea is known for subscribing heavily to the principle of self-reliance. If the rural communities are convinced and properly oriented to clearly understand the (link between OD and poor health their health) then there will be a high likelihood that the communities will accept the implementation of CLTS in their villages. However, for a successful implementation of CLTS to take place, the process must be carefully introduced and presented by committed and well trained CLTS facilitators who are conversant with PRA methods. Good facilitation is a crucial element for the success of the CLTS approach. For this to happen the MoH must organise a specially designed training for selected potential facilitators from the different ethnic groups (Natural Leaders) that will serve in their respective communities. Another factor that contributes towards successful CLTS is the attendance rate of community members in the triggering sessions where they are confronted by the reality of OD in their environment. The ideal attendance for the triggering is for every member of the community to participate. In general, the rule of thumb for attendance in triggering sessions is to aim for at least 80% of the population. If the attendance is under 50%, the triggering session will be postponed to another date until enough participants are mobilised. Missing a triggering session means missing the ignition moment when participants get disgusted of their own actions and collectively decide to abandon OD and build their own latrines. In the implementation of CLTS, Local Government technical staffs are in the forefront. Their roles in mobilising the communities cannot be overemphasised. It is encouraging to note that Regional and Sub-regional Authorities are enthusiastic about sanitation and hygiene activities in their respective regions. However, local authorities have to balance their efforts between constructing latrines and the rate of using those latrines. Ultimately it will be the rate of latrine use (behavioral change) that will ensure sustainable sanitation in the long run not the sheer numbers of latrines constructed. More importantly, for the local authorities to contribute positively towards the achievement of improved sanitation and hygiene, they must refrain from applying at times coercive approaches on the people which are contrary to the principle of CLTS 2
which advocates convincing rather than forcing communities to develop their own Action Plans to address their sanitation and hygiene challenges. 1.4 Rationale for the Assessment Eritrea has made remarkable progress in immunization coverage and reduction of malaria (Under-five mortality rate fell by almost 50%, from 147 per 1,000 Live Births (LB) in 1990 to 74 per 1,000 LB in 2006; child mortality is reduced from 68 to 48 per 1,000 LB, infant mortality from 72 to 48 per 1,000 LB, and post-neonatal from 41 to 24 per 1,000 LB and neonatal has marginally changed from 25 to 24 per 1,000 LB, and Expanded Program on Immunisation (EPI) coverage 95%, and reduction of malaria morbidity and mortality by over 80% (MoH 2008). It has however, remained as one of the countries with the lowest sanitation coverage globally and is not on track to meet the Millennium Development Goal (MDG) sanitation target of 54% by 2015. Poor sanitation and hygiene remains the main cause of preventable diseases such as diarrhea, and contributes substantially to the health burden in the country. The CLTS approach has therefore been adopted to contribute to the reduction of disease burden in the country. The current assessment survey is part of the regular monitoring of Water Sanitation and Hygiene (WASH) programmes currently being implemented in rural Eritrea. The overall justification of the assessment survey was to establish the current ODF status of the ODF declared villages as a means of measuring the sustainability of the CLTS programme. The assessment also looked at the availability of materials for the construction of latrines and the ability of communities to procure these materials. 1.5 Objectives of CLTS Sustainability Assessment The overall objective of the study is to establish levels of the sustainability of ODF status and to assess the key motivators to stopping open defecation and potential barriers which hinder long term behaviour change. 1.6 Limitations of the Assessment The target for the ODF sustainability assessment were households in villages declared ODF with data collected through quantitative and qualitative methods. The main limitation of the assessment was that it focused on household level and did not include on school or health centre data. The studies questionnaire did not cover questions on household income and wealth status, credit and loans or sources of finance etc. 1.7 Organisation of the report This report presents the findings of the assessment of sustainability of the ODF status of households in selected villages that have declared ODF between 2008 and 2014. 3
This report is divided into four chapters. Chapter 1 introduces the background and rational for the assessment. Chapter 2 presents the approach and methodology applied to implement the assessment; Study area and study design; target population and sample frame; sample size determination and sample selection; procedures followed for selecting villages and households; assessment instruments and implementation plans. Chapter 3 presents the detailed findings according the different sections of the assessment questionnaire as follows: household characteristics; community knowledge and participation in CLTS; water sanitation and hygiene; general defecation practices; latrine ownership, utilization and knowledge; hygiene practices; latrine perceptions; media and communication and physical observation. In Chapter 4 the conclusions drawn and recommendations for future action are presented. 4
2. APPROACH AND METHODOLOGY 2.1 Introduction The implementation of the Assessment was conducted in partnership between MoH and UNICEF. At Zoba level the MoH Environmental Health Division (EHD) was responsible for coordination and facilitation. Supervision of enumerators was carried out by MoH senior staff members from MoH HQ and UNICEF. The Zoba EHD heads and field enumerators were assigned to facilitate the FGD while the KIIs were handled by the supervisors. The assessment was implemented to collect data on key sanitation and hygiene indicators using desk review, field survey through structured questionnaires, Focused Group Discussions (FGDs), Key Informants Interviews (KII), and physical observation. 2.2 Study Area By December 2014, there were 578 villages that had achieved ODF status. It was envisaged that the assessment would provide important basis for continuity and scale up of the CLTS programme across the country. According to EPHS 2010, around 65 percent of the total population of Eritrea live in rural areas. The CLTS approach offers a means of accelerating the process of behavioral change from the established age-old practice of OD to ODF by abandoning OD through building and using household latrines in all rural villages. The assessment was planned to cover 117 randomly selected rural villages in all the six zobas. These villages account for 20 percent of the total number of ODF declared villages in the country. From within these villages 1,638 households were selected for interview. However four villages previously declared ODF had been relocated for a variety of reasons, therefore the actual number of selected ODF villages was reduced to 113 and the number of households interviewed to 1,580. 2.3 Study Design According to Kiregyera (1999), the concepts of Survey Design and Sample Design are often erroneously used interchangeably. However, these concepts are different. Survey Design sometimes refers to total survey design, relates to the entire process of conducting a survey, including sample design, field strategies that include recruitment and training of field and office staff, logistics, data collection, data processing and analysis, report writing and dissemination of survey results. Sample Design relates to the techniques for selecting a random sample and the method for obtaining estimates of survey variables from the sample data. Sample design therefore, involves among others: deciding on the sampling methodology (scheme); calculating the required sample size; and deciding on the selection procedure of sampling units. Through desk research, secondary data relevant to the assessment was consulted from limited locally produced documents (DHS 2002, EPHS 2010, Nationwide Assessment on Availability of 5
Water, Sanitation and Hygiene Facilities in Health Care Facilities, Ministry of Health, 2012 and The State of Eritrean Children, Ministry of Health 2008.). The assessment applied both qualitative and quantitative data collection methods. i. Quantitative survey: From a representative sample of female and male headed households, quantitative data on key indicators related to the following domains was collected: Household demographics; housing conditions and dwelling types, amenities; asset ownership; sanitation facilities; educational level, source of water and energy, etc. ii. Qualitative Survey: Using focus group discussions with cross section representatives of households in selected villages and key informant interviews with stakeholders. Such discussions and interviews were conducted to obtain an in-depth understanding of household living conditions, specifically in respect to water and sanitation, perception of the constraints they encounter in building and using their latrines, health extension services, satisfaction with latrine uses, and perception on the benefits of hand washing and latrine use. 2.4 Sample Selection For the study, a two-stage sampling methodology was applied to select representative sample of households from the ODF declared villages. The sampling scheme adopted was a Probability Proportional to Size (PPS), size being the number of households at the first stage where 20 percent of the ODF villages in each Zoba were selected. This was followed by Linear Systematic Sampling (LSS) at the second stage where a fixed number (14 households) from each selected ODF villages are selected for interview. 2.5 Target Population and Sampling Frame The target population for the assessment survey was the total number of households that reside in the ODF declared villages whose characteristics are to be studied. A sampling frame is a list of distinct and distinguishable units (in these case target households) of a given population from which a sample of households is selected using an appropriate sampling method. A sampling frame is an essential feature of any survey program. It is a means to access the households without which there can be neither a complete coverage nor a random sample. Hence the availability of a sampling frame (from existing list or newly constructed) is an important requirement /prerequisite for any Assessment work. To be useful, a sampling frame should be adequate, and should have the following qualities: Accurate where the units in the frame are defined precisely (target households) Complete where every head of household is listed once and only once, without any omission or duplication Up-to-date where the sampling frame is accurate and complete at the time when a sample is to be selected. 6
2.6 Sample Size Determination Sample size impacts directly on survey costs, the time required to complete the survey, the number of interviewers required and other important operational considerations, early decision about sample size was important. Recognising that too large a sample implies an inefficient use of resources and too small a sample diminishes the utility of the results, a 20 percent sample of ODF villages with 14 households from each selected village was used. The overall sample size for the assessment was determined by using a single population proportion based on key dichotomous variables from the household questionnaire. To determine the sample size to be selected, the following formula (Triola, 1995) was used. 1 where n 1= desired sample size Z= confidence interval (1.96) p= estimated prevalence rate (1-p)= proportion without the attribute of interest E= degree of precision (absolute error). Since there is no reliable data available on the proportion of households having latrines from previous studies, the proportion p was set at 50 percent (0.5) with a margin of error of 0.03 at the 95 percent confidence level. Using formula 1, n 1= Z 2 *p*(1-p)/e 2 = (1.96*1.96*0.5*0.5)/(0.03*0.03)= 1068 households. This figure is multiplied by 1.5 to account for Design effect for a two stage sampling and the outcome divided by 0.98 to account for non-response which gave 1068*1.5/0.98 = 1,635 households required to be interviewed at country level. The distribution of households per Zoba is presented in Table 1 below. 2.7 Procedure for Selecting Sample Villages 20 percent of the ODF villages in each Zoba was calculated from the total number of ODF declared villages. A list of all ODF villages in each Zoba with the total number of households was prepared. Starting at the top of the list, cumulative measures of size were calculated and entered next to the measure of size for each village. The sampling interval SI, was calculated by dividing the total cumulative measure in this case the total number of households in all the ODF villages in the Zoba by the already calculated number of villages in this case the 20 percent of all the villages. A random number (RS) between 1 and SI was generated using the spreadsheet function RANDBETWEEN (1, SI). This is the first random number called Random Start. Where this number fell in the cumulative measure column that village was selected. For the rest of the villages selection continued using RS+SI, RS+2*SI, RS+3*SI etc. until the required number of villages are selected. 2.8 Selection of Sample Households at the Second Stage 7
Sample households were selected from a sampling frame of all households in each selected ODF village using LSS. The list of households in selected ODF villages was collected from the Zoba Statistics and GIS Department of the Local Government Administration. Since a fixed number of 14 households from each selected village was required, a similar approach was adopted to select households in the second stage. First the sampling Interval (SI) was calculated by dividing the total number of households by 14. A random number between 1 and SI was selected as a Random Start. For the second household add SI to RS, then RS+2SI until 14 households are selected. A list of 14 selected households for canvassing was compiled with an additional 14 households selected as a reserve in case some households could not be traced at the time of the visit. Table 1 Distribution of sampled villages and households by Zoba Zoba Tot. No. of Total Sample of Tot. No. Of households No. of ODF households in ODF ODF Villages interviewed villages* Villages (20 percent) Anseba 23,813 106 21 292 Debub 14,908 133 27 378 Gbarka 28,124 152 29 406 Maekel 31,113 82 16 224 NRS 15,568 61 12 168 SRS 23,282 44 8 112 Total 136,808 578 113 1,580 *source: EHD zoba offices To collect quantitative data, 1,580 female and male headed households in 113 randomly selected villages were interviewed on face-to-face basis using a pre-structured questionnaire. 2.9 Implementation Phases The assessment was implemented in four distinct phases. Each phase had detailed activities to enable the collection of the required data as stated in the terms of reference (ToR). Due to the joint nature of management arrangement of the assessment, activities were assigned to specific individuals or partners. Phase 1 preliminary work This phase involved visits to the respective Zobas to collect list of villages and households by a team comprising of the consultant and staff member of the Environmental Health Division (EHD) of the MoH. In addition the following key activities were undertaken: Consensus building with all Zoba stakeholders (MoH, Local Government) on the timing of the assessment s field operations, Preparation of sampling frame of ODF villages and households for sample selection; Collection of other relevant secondary data on sanitation; 8
Design and pretesting of questionnaires and preparation of check list; Selecting of female and male supervisors and enumerators; Training of supervisors and enumerators; Pre-testing of questionnaires; Preparation and presentation of the inception report; Phase 2 Implementation (Field work) Phase two involved the following key activities: Printing, binding and distribution of questionnaires and lists of selected villages and households; Communication to local authorities about the administration of the assessment; Administering of questionnaires on selected female and male headed households; Supervision of data collection and inspection of filled in questionnaire for quality assurance; Data processing and Analysis of completed questionnaires; Conducting of FGD, KII and physical observation; Compilation of draft reports of FGD and KII findings; Phase 3 Data entry, cleaning, validating The key activities under this phase were: Registration and editing of questionnaires to ensure that questionnaires are accurately and completely filled out; Preparation of code book for data processing; Design of Data Entry Template in CSPRO; Training of data entry clerks on the structure of the Data Entry Template; Inputting of data into the pre-installed CSPRO Data Entry Template; Supervision of the data entry process; Conversion of the data from CSPRO format to SPSS format for further processing and analysis; Phase 4 Data analysis, interpretation and report writing The activities under this phase were; Generating Frequencies, Graphs and tables; Preparation of draft report and presentation of findings to the client for their comments and input; Amendment of draft report incorporating client input and production of final report; Facilitation of national workshops; and Submission of final report and documents; 2.10 Assessment Instruments The quantitative assessment was carried out through a series of steps. The target population was defined, a sampling frame which included all of the population units was identified, sample elements (target households) were selected from the frame, reporting units to whom questions would be asked were identified, and respondents were interviewed with the help of instruments and check lists. 9
The assessment used two instruments: a quantitative household questionnaire; and a set of qualitative interview questions for focus group discussions and Key Informants Interviews. The questionnaires and focus group interview questions were translated from English into Tigrigna. The translator asked respondents in local language and translated responses back into Tigrigna for recording into the questionnaire by the enumerators. This back and forth translation between enumerator, translator, and respondent whilst time consuming was considered the best approach to ensure reliable communication and understanding between enumerator and respondent and minimising errors. The household questionnaire (Annex 4) was composed of 11 sections, which included: background, household particulars, community knowledge and participation in CLTS, Water, Sanitation and Hygiene, Latrine ownership, Utilization and knowledge about hygiene, latrine perceptions, media and communication, multi-item scales, and latrine observations. The majority of responses were pre-coded with same spaces for Other specify responses. One of the sections was devoted to physical observation of compounds/yards and latrines of responding households. For the qualitative approaches two additional semi-structured questionnaires and check lists for Focus Group Discussions and key Informants Interview were prepared. These were also translated into Tigrigna from English and printed in both languages. The Community FGD were carried out with men s and women s groups in eight villages each of which represented one ethnic group with the exception of the Rashaida and Saho which had no ODF villages selected in the sample. The community leaders were instructed to mobilise 8-12 representatives comprising men and women from the village. The brief FGD reports for NRS are presented as Annex II. 2.11 Selection and Training of Enumerators and Supervisors. The MoH identified 40 of its staff members from the Ministry Headquarters and Zobas to participate in the assessment. Six of these were nominated to be supervisors and the remaining 34 served as enumerators. All the enumerators and supervisors participated in a one week training held prior to the field data collection. The training included sessions on the purpose of the survey, the role and responsibilities of the enumerators and supervisors, dealing with respondents, role playing and mock interviews in class. The training was followed by a pretesting exercise which was implemented in two rural villages in Zoba Maekel. The feedback from this pilot was included in the final version of the questionnaire. The training programme was designed to familiarise the enumerators and supervisors with the questionnaire both in English and Tigrigna. The purpose of each question was explained and then the instructions on how to fill in the responses and skip patterns were reviewed. The training was conducted over six days between April 15 and April 21, 2015. 10
3. FINDINGS OF THE ASSESSMENT The basic profile of respondents such as the number and their distribution by Zoba, gender, marital status, age, household head, educational attainment, residential status and family size are presented in the following paragraphs. There were 1,580 household respondents interviewed from 6 Zobas, 46 Sub-Zobas and 113 villages. The respondents were randomly selected from 20 percent of the ODF declared villages in each Zoba. 3.1 Classification of the Respondents The criteria for potential respondents for the assessment were male and female heads of households and in their absence their spouses, oldest sibling or a close adult relative. From the estimated 1,624 respondents spread in the six Zobas, 1,580 (97.3 percent) were canvassed. Of these, household heads were the majority of respondents accounting for 45.9 percent, followed by Spouses of head (39.6 percent), eldest sibling (11.1 percent) and only (3.3 percent) for others. Of the 1,580 respondents that were interviewed, 1,568 responded to the question on relationship to the head of household. This accounts for 99.2 percent response rate for the specific question on the relationship between the respondent and head of household. The percentages of the relevant relationships are presented in Fig. 1 below. 3.2 Distribution of Respondents by Zoba As depicted in Fig. 2 below, both Debub and Gash Barka held the largest numbers of respondents due to the high number of ODF villages in these two Zobas. Whilst 50 percent of the respondents are from both Gash Barka (26 percent) and Debub (24 percent), the remaining 50 percent of the respondents were divided between Anseba (18 percent), Maekel (14 percent), NRS (11 percent) and SRS (7 percent). 11
3.3 Sex of Respondents and Household Heads Figure 3 shows the comparison between Respondents and Heads of households classified by Gender. The respondents were composed of Males (31.8 percent) and Females 68.2 percent. The selection of the respondents in a household was dependent upon who was present at home during the day of the interview. In comparison to the results of the EPHS 2010 which showed 56 percent of the households as being male headed and 44 percent as female headed households, the current assessment found 72 percent male headed and 28 percent female headed households. The ratio of male headed to female headed household in 2010 was 56/44= 1.3 while for the current assessment the male headed to female head households ratio is 72/28= 2.6 indicating that the number of male headed households are 2.6 times the female headed households. The distribution of heads of households in the different Zobas is presented in Table 2. The dominance of male headed households in terms of number is present in all the Zobas. 12
Table 2 Regional Distribution of Household Heads by Gender Zoba Total Anseba Debub Gash Barka Maekel NRS SRS Male Female Total Count 225 67 292 Percent 19.8% 15.2% 18.5% Count 225 152 377 Percent 19.8% 34.5% 23.9% Count 306 100 406 Percent 27.0% 22.7% 25.8% Count 160 64 224 Percent 14.1% 14.5% 14.2% Count 124 42 166 Percent 10.9% 9.5% 10.5% Count 95 16 111 Percent 8.4% 3.6% 7.0% Count 1,135 441 1,576 Percent 100.0% 100.0% 100.0% The distribution of respondents by Zoba and gender is presented in Fig. 4 below. 3.4 Demographic Profile of Selected Households Table 3 depicts the total population disaggregated by age groups within the 1,580 households interviewed. The total population of 9,461 individuals are almost equally divided between males at 49 percent and females at 51 percent with an overall male: female ratio of 0.97. Slightly under half (46 percent) of household members are adults (18 years old and above), 38 percent are children (aged 6-17), and 16 percent are children under five years including infants. 13
Table 3 Distribution of population by age category and Gender Age group Males Females Total Percentage Children under 5 years 754 741 1,495 16 percent Children 6-17 years 1,870 1,727 3,597 38 percent Adults 18-65 years 1,775 2,115 3,890 41 percent Adults over 65 years 259 220 479 5 percent 100 Total 4,658 4,803 9,461 percent Percentage 3.5 Family Size 49 percent 51 percent 100 percent Family size within the interviewed households ranged between 1 and 25 members with an average family size of 6 members per household. The households containing 4-9 persons are the majority accounting for 70 percent. The average family size of 6 members is higher when compared to the average household size of 4.8 persons from the EPHS 2010. The distribution of family sizes of households is presented in Fig. 5. 3.6 Household Structure As indicated in Table 4, 77.3 percent of the assessed households were of nuclear type, i.e., composed of parents and their children. Another 19.8 percent were of extended households having additional relatives staying on permanently as members. Three per cent of the households have only one member, or are single households. Gash Barka have the highest number of nuclear households (349 households) followed by Debub (301 households), Anseba (211 households), Maekel (161 households) and NRS (113 households); while extended households were found highest in Anseba (78 households) followed by Debub (61 households) Maekel (55 households) and NRS (54 households). The 14
majority of single households were found in both Debub and Gash Barka (16 households) each and Maekel (8 households) and Anseba (3 households). Table 4 Distribution of type of Households by Zoba in Percentages Zoba Nuclear Extended Single Anseba 72.3 percent 26.7 percent 1.0 percent Debub 79.6 percent 16.1 percent 4.2 percent Gash Barka 86.0 percent 10.1 percent 3.9 percent Maekel 71.9 percent 24.6 percent 3.6 percent 67.3 32.1 0.6 NRS percent percent percent 77.7 21.4 0.9 SRS percent percent percent N 1222 313 45 Total 77.3 percent 19.8 percent 2.8 percent Descriptive statistics for the variables age of respondent and head of household are presented in Table 5. Both variables had very high response rate at 99.8 percent and 99.5 percent respectively. Table 5. Descriptive Statistics for Age of Respondent and Age of Head of Household Age respondent Age HHH Valid N 1,577 responses 1,572 responses Missing 3 8 Mean 43.58 years 51.75 years Median 40.00 years 50.00 years Mode 30 years 50 years Minimum 14 years 14 years Maximum 92 years 95 years The age distribution of respondents is presented in Fig 6 below. The age of heads of households ranged between 14 and 95 years with an average age of 51.75 years, while that for respondents ranges between 14 and 92 years with an average age of 43.58 years. There is a higher concentration on the years ending in zeros and fives. This is clearly noticeable in Fig. 6 below. 15
3.7 Marital Status of Heads of Households The majority of the heads of households, 81 percent, are married followed by widowed at 12 percent and divorced at 5 percent. Only a small proportion of the respondents, 2 percent, are single or separated, 0.5 percent. The result of the marital status of the assessed households is presented in Fig 7. 16
3.8 Religious Affiliation The 1,580 heads of households are almost equally divided between followers of the two predominant faiths in the country Christians 49.7 percent and Moslems, 50.3 percent. Table 6 Latrine ownership and use Do you have a Does your latrine family use your latrine Religion Yes (%) No (%) Yes (%) No (%) Christian 587(48.3) 191(53.5) 488(46.0) 25(92.6 ) Moslem 628(51.7) 166(46.5) 573(54.0) 2(7.4) N 1,215 357 1,061 27 In terms of latrine ownership there is little difference between respondents who are Moslems and Christians. However as depicted in Table 6, there is a difference of eight percent in terms of latrine use between the two groups. 3.9 Ethnic Groups The distribution of the number of heads of households presented in Fig.9 shows that the majority, 45.8 percent, belonged to the Tigrigna ethnic group followed by Tigre at 27.8 percent. The remaining ethic groups account for 25.2 percent. The majority of the Tigrigna ethnic group is found in Maekel, Debub and partially in Anseba and Gash Barka. Tigre are found in NRS, Anseba, and Gash Barka. The remaining ethnic groups are found in specific areas like the Saho in Debub, Nara, Kunama and Hedareb in Gash Barka, Bilen in Anseba and Afar in SRS and NRS. The ethnicity question was answered by all 1,580 respondents. 17
3.10 Educational Level of Heads of Households The question on educational attainment was answered by 1,579 respondents. Figure 10 shows that 39 percent of the heads of households are illiterate. Those who are literate account for only 13 percent of respondents. Those with elementary, junior secondary, secondary and postsecondary level of education account for 27 percent, 11 percent, 9 percent and 1 percent respectively. The assessment investigated correlation between the educational level of household heads and level of latrine ownership, maintaining their ODF status and repairing latrines. The results as presented in table 7 which does not indicate any evidence that education has influenced households in their decisions to own latrines, maintain their ODF status or maintain their latrines. Table 7 Educational Level of Head of Household by Latrine Ownership, ODF Status and Maintenance of Latrine Educational level of Household Do you have a latrine? Is your household maintaining its ODF status Did you maintain/ repair your latrine after it was damaged Head Yes No Yes No Yes No Illiterates 446 168 351 171 83 32 Read and Write 163 46 141 44 31 11 Elementary 345 83 289 88 76 26 Junior 144 23 120 29 23 9 Secondary 101 33 82 34 11 4 18
Post- Secondary 14 3 12 1 2 0 IDK 1 1 1 1 - - Total 1,214 357 996 368 226 82 3.11 Occupation of Head of Household 62.3 percent of all interviewed households are engaged in agriculture with the dominant occupation being farmer, followed by housewife and salaried employee at 12.0 percent and 11.7 percent respectively. The distribution of occupations in the different Zobas is presented in Table 8. The majority of the household heads are farmers followed by housewives and salaried employees. In SRS the prominent occupation is livestock herding. Table 8 Regional Distribution of Occupation of Heads of Households Occupation of Head of Household Zoba Farmer Livestock Daily Artisan Petty Salaried House Fisher Herder Laborer Trader Employee Wife Man Total Anseba 191 1 10 2 9 37 42 0 292 Debub 276 0 1 3 2 29 65 0 376 Gash Barka 294 3 12 7 23 50 17 0 406 Maekel 133 3 8 6 6 44 24 0 224 NRS 88 13 14 5 12 7 25 4 168 SRS 2 48 5 1 8 17 17 14 112 Total 984 68 50 24 60 184 190 18 1,578 19
3.12 House Ownership Out of the 1,567 (99.2 percent) of households that responded to the question on home ownership, the majority (91.4 percent) of households own their homes. A small percentage (4.7 percent) are tenants and the remaining (4 percent) of the households occupy units for free. 3.13 House Structure A total of nine types of houses or dwelling units were provided to the respondents as options to choose from based on traditional rural Eritrean designs. These were:- Hudmo traditional house with walls of stone with mud cement with soil and wood roof. Merebae Stone walls with corrugated tin roof. Hut mud construction with grass roof. Agnet simple house made from straw mats. Meadeny wooden house with grass or leaf roof traditional lowland house. Villa Concrete construction with tiled roof Service concrete constructed villa with outbuildings Ground +1 multi storey villa. Tent fabric construction The three dominant types of houses are Huts (Stone, mud or wood walls with grass roof) 9 at 41.4 percent, Merebae (hut with tin roof) at 36.8 percent and traditional house known as Hudmo (stone or mud with soil roof) at 14.1 percent. In the highlands of Eritrea Hudmo used to be the main type of house; however it is being replaced by Merebae in recent years. The Merebae with corrugated zinc roofs have extra advantage for water harvesting during the rainy season. Many households collect rainwater from their roofs during the rainy season minimising the time spent to fetch water. The results of the cross tabulation of type of house by latrine type is presented in Table 9. Table 9 Distribution of type of Latrine by Type of House Type of Latrine Flush/pour Pour Ventilated Pit latrine Type of House flush to flush to improved Pit latrine without slab/ Total septic tank pit pit with slab open pit latrine Traditional House 3 6 15 71 86 181 Hudmo Merebae 43 36 38 229 129 475 Villa 3 0 1 3 0 7 Ground +1 1 1 0 0 0 2 20
Service 9 7 0 9 2 27 Hut 25 56 34 148 191 454 Agnet 2 0 3 17 7 29 Tent 0 0 0 1 0 1 Meadeni 0 3 2 29 0 34 Total 86 109 93 507 415 1210 3.14 Type of Wall and Roof Structure The assessment results indicate that the majority of the houses have roofs of corrugated zinc at 38.2 percent, thatch at 37.3 percent, soil and wood at 15.5 percent, doum palm (straw) mats at 6.8 percent, concrete at 2.1 percent and plastic sheet at 0.1 percent. 3.15 Type of Floor The majority, 77.3 percent, of houses of the assessed households had soil or sand floors. Concrete floors accounted for 20.3 percent followed by tiled floors at 2.4 percent and wooden floors stand at 0.1 percent. These results are represented in Fig 13. 21