Our Mission We are Christians committed to ending the global water and sanitation crisis.

Our Vision Thousands equipped, millions served, and a movement of transformed people serving together to end the global water and sanitation crisis.

About Lifewater International

Lifewater is a non-profit, Christian water development organization dedicated to effectively serving vulnerable children and families by partnering with underserved communities to overcome water poverty.

With experience in more than 40 countries over 37 years, Lifewater serves all people of all faiths. Our programs are strategically prioritized to serve vulnerable children and families living in remote, rural, and hard-to-reach regions of our world.

As a Christian organization, we are called by Jesus to love and serve the poor in an empowering and transformational manner. While some Christian organizations are called to feed the hungry, shelter the homeless, or plant churches, Lifewater International is called to bring water, health, and hope to the world’s most vulnerable people using our community-focused approach.

We believe, as Jesus taught, that when we serve the poor, we are serving Him. We treat each community, family, and person with dignity and respect. We view every interaction as an opportunity to reflect God’s love in world and in deed.

“But in your hearts revere Christ as Lord. Always be prepared to give an answer to everyone who asks you to give the reason for the hope that you have. But do this with gentleness and respect.” 1 Peter 3:15 (NIV)

Lifewater International is a 501(c)(3) non-profit.

Copyright This training material is published by Lifewater, Inc. under the open content copyright provisions and its license is available under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License on the website: http://creativecommons.org/licenses/by-nc-sa/3.0/ -or- through sending a letter to Creative Commons, 171 Second Street, Suite 300, San Francisco, California, 94105 USA.

Attribution Non-Commercial Share Alike You are free: 1. To Share - copy, distribute and transmit the work 2. To Remix - to adapt and/or translate the work

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DISCLAIMER- Lifewater International and its directors, employees, contractors, and volunteers do not assume any liability for and make no warranty with respect to the results obtained from the use of the information provided.

Lifewater aims to maintain relationship with users of this work in order to learn from one another and obtain feedback on implementation. Therefore, organizations wanting to use this work are asked to sign a simple partnership agreement outlining specific terms of use. Please contact Lifewater International for more information: [email protected] Lifewater International P.O. Box 3131 San Luis Obispo, CA 93403 Telephone: +1.805.541.6634 www.lifewater.org

mWASH Training Manual: Table of Contents

Overview of mWASH Manual ...... 5 Section 1. Foundations of mWASH: Introduction ...... 6 Lesson 1.1: Transformational Development ...... 7 Lesson 1.2: Key Community Development Principles ...... 11 Lesson 1.4: Intro to mWASH ...... 15 Section 2. Community Health and WASH ...... 18 Lesson 2.1: WASH-Related Disease Transmission ...... 19 Lesson 2.2 WASH-Related Diseases ...... 22 Lesson 2.3: Diarrhea Care & Treatment ...... 24 Lesson 2.4: The Sanitation Ladder ...... 28 Lesson 2.5: Cleaning Latrines ...... 33 Lesson 2.6: Handwashing at Critical Times ...... 36 Lesson 2.7: Effective Handwashing ...... 39 Lesson 2.8: Making Water Safe ...... 43 Lesson 2.9: Keeping Water Safe ...... 48 Lesson 2.10: Keeping Food and Utensils Clean ...... 50 Lesson 2.11: Infant and Woman Health ...... 52 Lesson 2.12: Environmental Hygiene ...... 56 Section 3. Framework for Change: Introduction ...... 59 Lesson 3.1: Behavior Change ...... 60 Lesson 3.2: Community-Led Total Sanitation ...... 64 Lesson 3.5: CLTS - Ignition Moment ...... 68 Lesson 3.6: CLTS - Post-Triggering Stage ...... 71 Lesson 3.7: Total Sustained Change ...... 73 Lesson 3.8: Adapting Communication Methods ...... 76 Lesson 3.9: Adapting Learning Tools ...... 78 Lesson 3.10: Adapting Attitude ...... 81 Section 4. Program Strengthening ...... 85 Lesson 4.1: Strengthening Discussion Questions ...... 86 Appendix ...... 88 Appendix 1: Key Community Development ...... 88 Appendix 2: Sugar Salt Solution Recipe and Directions ...... 89 Appendix 3: Tippy Tap Instructions ...... 91 Appendix 4: Alternative Water Purification Methods ...... 93 Appendix 5: SODIS Diagram ...... 96 Appendix 6: Triggering Activities - Transect Walk ...... 97 Appendix 7: Triggering Activities - Community Mapping ...... 99 Appendix 8: Triggering Activities - Shit Calculation ...... 102 Appendix 9: Triggering Activities - Feces Flow Diagram ...... 104 Appendix 10: Alternative Community Triggering Option Part 1 ...... 107 Appendix 11: Alternative Community Triggering Option Part 2 ...... 109 Appendix 12: Focus Group Discussion ...... 111

mWASH Manual Foundations of mWASH Introduction

Overview of mWASH Manual CURRICULUM LAYOUT: Each lesson will begin with the materials, preparation and time needed. These can all be adjusted depending on what is available and appropriate for each community.

BACKGROUND: Each lesson will have Background information to support the facilitator. Each facilitator may decide which points to share with participants.

DISCUSSION QUESTIONS: These questions are to encourage dialogue with participants. Facilitators are encouraged to change or add to these as needed.

APPENDIX: The appendix is located at the end of the manual. It contains supporting information, optional dramas and activity ideas for facilitators.

RESOURCE PACKET: The resource packet contains posters and other materials required for lessons.

BIBLE VERSION: This manual uses the International Reader’s version for all Bible Verses.

5 mWASH Manual Foundations of mWASH Introduction

Section 1. Foundations of mWASH: Introduction

The first section of this manual lays a foundation for practicing effective transformational development. Transformational development is the process of bringing lasting physical, social, and spiritual change. This section considers key principles a community development practitioner should consider, and provides an overview of transformational development through water, sanitation, and hygiene.

6 mWASH Manual Foundations of mWASH Lesson 1.1: Transformational Development

Lesson 1.1: Transformational Development

Purpose of Lesson: • To understand our role in personal and community transformation Objectives: • To learn what God intended relationships to be, what they currently are, and how God is restoring them • To learn about the process of transformation • To show God’s love through our actions Materials: • Flipchart or large piece of paper • Markers • Optional: Bibles Preparation: 1. Draw the 3 images below on separate pieces of flipchart paper. 2. Prepare volunteers to read Bible verses listed in sections 3 and 4.

Time: 65 minutes

7 mWASH Manual Foundations of mWASH Lesson 1.1: Transformational Development

1. Introduction Learning Questions: 5 minutes

Begin with a discussion of the participants’ work using the following discussion questions. If participants only mention physical problems or effects, explain that a lot of community development work is based on physical problems and physical solutions. When our goal is improved health, we often look to physical reasons for illness and work to solve them. Similarly, when we think of the physical problems we are working to address in our work, we think about the physical benefits that solving these problems give like access to safe water or improved health. But we don’t always think of ways physical problems affect and are affected by people’s emotions, attitudes towards God, and relationships with other people.

Introduction Learning Questions: • What is the main goal of the work that you do in communities? • What is the main problem that you are trying to solve? • What are some of the major causes of the problem? • What are some of the major effects of the problem?

2. Broken Relationships: 20 minutes

Use this lesson to examine the participants’ own motivations for wanting to do work in communities. In summary, Christians are called to be part of God’s work in restoring relationships that sin broke. Development work is more than improving people’s quality of life or wellbeing; it is restoring people’s relationship with God, with one another, and with the environment.

First, explain to participants the Story of Creation summarized below. Then show the first image that was drawn on a flipchart of the perfect relationship, shown by solid lines, between humans and God, humans and other humans, and humans and the environment.

Story of Creation: God created the world, and called it good. Not only was the creation beautiful but also everything in it worked well according to God’s intended design. Relationships were as God meant them to be. God and people and all of God’s creation lived in peace and harmony.

Second, explain the Story of the Fall summarized below and have volunteers prepared to read the Bible verses listed. Then show the second image of broken relationships, shown by jagged lines.

Story of the Fall: (Show participants the broken relationship diagram) When the first man and woman rebelled against God, brokenness entered the world. Now, things no longer work the way they are supposed to – all relationships are damaged by sin.

Examples from the Bible about broken relationships:

• “But your sins have separated you from your God. They have caused him to turn his face away from you. So he won't listen to you.” -Isaiah 59:2 • “The people of the land get rich by cheating others. They steal. They crush those who are poor and in need. They treat outsiders badly. They refuse to be fair to them.” -Ezekiel 22:29

8 mWASH Manual Foundations of mWASH Lesson 1.1: Transformational Development

• “So I am putting a curse on the ground because of what you did. All the days of your life you will have to work hard to get food from the ground. You will eat the plants of the field, even though the ground produces thorns and thistles.” -Genesis 3:17-18

Use the facilitation questions below to start a conversation with participants about broken relationships in their lives.

Discussion Questions: • Broken relationships lead to both physical and spiritual poverty in the world. In this area, what are examples of physical poverty? • What are examples of spiritual poverty?

3. How Jesus Restores Relationships: 20 minutes

Explain to participants the Story of Redemption, summarized below. Explain to participants that the process of redemption starts with an individual believing in and following Jesus and choosing to be transformed through the power of the Holy Spirit. Because of the Holy Spirit and Jesus’ payment for our sins, our relationship with God has been restored. Jesus’s love is transformative and can reconcile our relationships with others and the rest of creation. Humans can restore the earth so that it can provide basic needs as God originally intended. Show the third diagram of a restored relationship between humans and God, shown by a solid line, and the process of restoration between humans and other humans and humans and the environment, shown by dotted lines. Explain that the reason for the dashed lines is that this transformation is still in process and not complete. Have volunteers read the Bible verses listed below.

Story of Redemption: (Show participants the restored relationship diagram) The good news is that God has a solution to brokenness. The dominant theme of the Bible, from Genesis to Revelation, is God’s plan to restore all broken relationships to their intended harmony or peace. Jesus Christ broke the power of sin and began the process of reconciliation, of restoring peace. This is sometimes called redemption.

Examples from the Bible about restored relationships:

• “We have been made right with God because of our faith. Now we have peace with him because of our Lord Jesus Christ. Through faith in Jesus we have received God’s grace. In that grace we stand. We are full of joy because we can expect to share in God’s glory.” -Romans 5:1-2 • “God was pleased to have his whole nature living in Christ. God was pleased to bring all things back to himself because of what Christ has done. That includes all things on earth and in heaven. God made peace through Christ's blood, through his death on the cross.” -Colossians 1:19-20

9 mWASH Manual Foundations of mWASH Lesson 1.1: Transformational Development

Discussion Questions: • What would spiritual transformation look like in the communities in which you work? • What would physical transformation look like in the communities in which you work? • How can God restore the broken relationships between people and the rest of Creation? • Does anyone have an example of how God has restored a broken relationship in his or her own life?

4. Optional Activity: Drama About God’s Love: 20 minutes

Break participants up into small groups and instruct them to make a list of ways they can demonstrate God’s love as they work in communities. Give participants a piece of flipchart paper to list their ideas. After each group has finished, instruct them to think of a drama that uses 1 or 2 of their ideas.

10 mWASH Manual Foundations of Development Lesson 1.1: Key Community Development Principles

Lesson 1.2: Key Community Development Principles

Purpose of Lesson: • To learn the 4 key principles of development Objectives: • To learn the difference between relief and development • To learn how Bible passages relate to the physical and spiritual aspects of people • To identify the difference between capacity building and multiplication Materials: • Flipchart or large piece of paper • Tape • Markers • Optional: 4-5 Bibles Preparation: 1. Write definitions of holism, capacity building and multiplication on a flipchart and cover up definitions by taping paper over them. 2. Prepare a flipchart of the Holism Chart using the example in Appendix 1. 3. Write the Capacity Building and Multiplication Verses on a flipchart. 4. Select 3 volunteers for River Crossing Drama (Activity 2) and instruct them to act out the River Crossing Drama using the instructions in Activity 2. Time: 70 minutes

Background • Relief may be defined as the “urgent provision of emergency aid to reduce immediate suffering during a crisis.”1 During and following a disaster, individuals and communities are often unable to meet their needs on their own and need urgent help. • Development focuses on the long-term process whereby individuals and communities sustainably improve their quality of life. Effective development involves long-term transformation and sustainable solutions that will permanently change the situation of a community. Jesus modeled 4 important key principles of community development: o Inclusion: Providing the opportunity for everyone to participate in activities and projects. o Holism: The balance between the physical and spiritual aspects of life. o Capacity Building: The process of developing the abilities of an individual, organization, or community to improve the effectiveness of the work. o Multiplication: Increasing in number by training people who will train others.

1 Steve Corbett & Brian Fikkert, When Helping Hurts: How to alleviate poverty without hurting the poor (Chicago: Moody, 2009), 104. - See more at: http://lifewater.org/articles-category/relief-vs-development/#_ftn1

11 mWASH Manual Foundations of mWASH Lesson 1.2: Key Community Development Principles

1. Introduction Learning Questions: 5 Minutes

Use the introduction questions to assess the participant’s current knowledge about relief and development.

Introduction Learning Questions: • What do you know about relief and development? • Are they the same or different? • If different, in what ways?

2. Drama About Relief and Development: 20 minutes

Introduce the drama to the participants; explain that it demonstrates the different ways help can be provided.

River Crossing Drama

Friends 1 & 2: The 2 friends want to cross the river but they do not know how to swim. The river’s current is strong and they are afraid to cross.

Stranger: The stranger walks up to the 2 friends and recognizes that they want to cross the river but are too afraid. He offers to help them by carrying 1 of the friends on his back. The stranger can only get to an island in the middle of the river with the friend on his back. He puts the friend there while he goes back to get the other friend. By the time the stranger gets back to the shore, he cannot carry the second friend because he is so tired. Instead, he agrees to teach the second friend how to walk across the river by showing him/her how to find the stones to step on. This friend then crosses the river and makes it to the other side.

Friend 1: Meanwhile, Friend 1 is still standing on the island shouting for help.

Stranger: The stranger wants to help the first friend but realizes he needs to leave. Instead, the second friend who learned how to cross the river instructs the friend how to cross the river. The stranger watches and encourages while the friend crosses the river.

Activity Questions: • What did you see happening in the drama? • What were different ways people were helped in the drama?

Clearly define relief and development and describe how they are different from each other. To help with this, use the Background section. Explain that in this course, the main topic will be development rather than relief.

Discussion Questions: • When do you think relief is needed? • When do you think development is needed?

12 mWASH Manual Foundations of mWASH Lesson 1.2: Key Community Development Principles

3. Inclusion: 5 minutes

Begin by explaining that effective development helps bring reconciliation using 4 important key community development principles that were modeled by Jesus. These principles are:

o Inclusion o Holism o Capacity Building o Multiplication

Reveal the definition for inclusion and ask a volunteer to read it. • During the drama, what different ways were the two friends “included”? • Why is it important to consider carefully the way in which people are included in a development project?

4. Jesus’ Holism: 20 minutes

Uncover the definition of holism. Ask a volunteer to read the definition for holism. Break participants up into 4 groups and assign each group one of the following holism Bible passages. Uncover the flipchart with Holism Chart drawn on it. Instruct participants to read their Bible passage and decide whether Jesus is meeting physical needs, spiritual needs or both types of needs. After 10 minutes, ask groups to come back to the circle to share what they discussed and place an “x” in the appropriate column on the large flipchart.

Holism Bible Passages: • Matthew 10:42 (giving a cup of cold water) • Matthew 9:1-8 (Jesus healing the paralytic) • Matthew 12:9-13 (Jesus healing a man’s hand) • John 5:5-14 (Jesus healing an invalid man)

Activity Questions: • What did you notice in these passages about the needs Jesus met? • In which of the passages can you see Jesus’ holism? • Why is it important to practice holism in a development program?

5. Capacity Building and Multiplication Within Scripture: 20 minutes

Uncover the definitions of the next 2 key development principles: capacity building and multiplication. Ask volunteers to read the definitions of capacity building and multiplication. Then, show the flipchart with Capacity Building and Multiplication Bible Verses. Read the Bible verses out loud to the participants. After each verse, ask whether the verse is an example of capacity building or multiplication or both. Finally, use the discussion questions below to consider with participants how these principles relate to development work.

Scripture about capacity building and multiplication:

13 mWASH Manual Foundations of mWASH Lesson 1.2: Key Community Development Principles

• “Jesus called the Twelve together. He gave them power and authority to drive out all demons and to heal sicknesses. Then he sent them out to preach about God’s kingdom and to heal those who were sick.” -Luke 9:1- 2 • “I, your Lord and Teacher, have washed your feet. So you also should wash one another’s feet. I have given you an example. You should do as I have done for you.” -John 13:14-15 • “I do not call you servants anymore. Servants do not know their master’s business. Instead, I have called you friends. I have told you everything I learned from my Father.” -John 15:15 • “You have heard me teach in front of many witnesses. Pass on to men you can trust the things you have heard me say. Then they will be able to teach others also.” -2 Timothy 2:2

Discussion Questions: • In what ways are the principles of capacity building and multiplication connected? • How do you see the principles of capacity building and multiplication at work in these verses? • Why are these principles important for effective community development? • Turn to a neighbor and discuss which of the key community development principles is easiest to practice, and which is most difficult.

14 mWASH Manual Foundations of mWASH Lesson 1.4: Intro to mWASH

Lesson 1.4: Intro to mWASH

Purpose of Lesson: • To learn how poor WASH can lead to broken relationships Objectives: • To learn the meaning of WASH • To think of WASH-related problems that need to be fixed Materials: • Flipchart or large piece of paper • Markers • Tape Preparation: 1. Write the definition of WASH on a flipchart using the definition in the Background section below. Time: 30 minutes

Background • mWASH: m= Missional o The way we work which brings about reconciliation and restored relationships between God and humans, between humans and other humans, and between humans and the environment/Creation WA= Water Access o Access to safe water sources S= Sanitation o Safe disposal of human feces and wastewater H= Hygiene o Cleanliness behaviors such as • Handwashing • Cleaning latrines • Covering stored water containers • An estimated 88% of diarrheal deaths worldwide are due to unsafe water, inadequate sanitation, and poor hygiene.2 • Handwashing with soap could reduce risk of diarrheal disease by 47% and save at least 1,000,000 lives per year.3 • 37% of the world’s population lives without improved sanitation (latrines).4 Improving sanitation facilities reduces incidence of diarrhea by roughly 36%.5

2 Black R.E., Morris S.S., and J. Bryce, “Where and Why are 10 Million Children Dying Every Year?” The Lancet, Volume 361, Issue 9376, Pages 2226-34, 28 June 2003. 3 Curtis, V., Cairncross, S., “Effect of washing hands with soap on diarrhea risk in the community: a systematic review.” The Lancet Infectious Diseases, Volume 3, Issue 5, Pages 275 – 281, May 2003. 4 Progress on Drinking Water and Sanitation 2012 Update. JMP Report 2012. 5 Jamison, D.T., et al. (editors), Disease Control Priorities in Developing Countries (Second Edition), London School of Hygiene and Tropical Medicine, London, 2008.

15 mWASH Manual Foundations of mWASH Lesson 1.4: Intro to mWASH

1. Introduction Learning Questions: 5 minutes

Use the facilitation questions below to start a conversation about some of the problems that communities deal with related to water, sanitation, and hygiene.

Introduction Learning Questions: • In communities where you work, what problems do they face related to water, sanitation, and hygiene? • How do these things affect the lives of community members? • How would people’s lives be different if these weren’t problems?

2. Definition of WASH: 15 minutes

Introduce the acronym “WASH” to the participants and explain that WASH is an acronym used around the world for Water Access, Sanitation, and Hygiene. Do not introduce the “m” for “mWASH” yet. Do not define these words or give any further explanation yet. First, have a discussion to learn the cultural understanding, meaning, examples, and significance of these words. Use the questions below to guide this discussion.

Introduction Learning Questions: • What do you think of when you hear the word water? • What does water mean to the communities in which you work?

• What do you think of when you hear the word sanitation? • What would people in communities say if you asked them what the word sanitation means?

• What do you think of when you hear the word hygiene? • What does the word hygiene mean to people in communities where you work? • If you asked people in communities about hygiene, would they say that they had good hygiene or poor hygiene? Why or why not?

Show participants the WASH acronym flipchart showing the definition (do not introduce the mWASH yet). Explain what Lifewater means when we use the words water, sanitation, and hygiene. Use the discussion questions below to learn more about these terms and practices.

Introduction Learning Questions: • Are there any local beliefs relating to water? • What do parents usually teach their children about defecation practices? • Are there any local beliefs about where people can or should defecate? • Are there any local customs or traditions about what people should do after they defecate? • What are different ways that people in communities wash their hands?

Use the WASH definition (do not include “m”) and facts in the Background section to give participants more information about problems related to WASH.

16 mWASH Manual Foundations of mWASH Lesson 1.4: Intro to mWASH

3. mWASH: 10 minutes

WASH is a very common term that many organizations around the world use to describe the global water and sanitation crisis and how important water, sanitation, and hygiene are to people’s physical health. Explain that Lifewater uses the term mWASH to describe the way in which we work. Because we seek to bring reconciliation and restore relationships beyond just the physical impacts of water, sanitation, and hygiene, we use the term mWASH. Use the definition of mWASH (particularly “m”) in the Background section to explain what mWASH means. Lifewater believes that the problems communities face are both physical and spiritual, and the solution must also be both.

Discussion Questions: • How can a WASH program help restore broken relationships? o Between people and God? o Between people? o Between people and the environment?

17 mWASH Manual Framework for Change Introduction

Section 2. Community Health and WASH

The lessons in this section covers WASH-related disease transmission, including diseases caused by poor WASH behaviors, proper treatment of diarrhea, and prevention of these diseases. Every year millions of schooldays are missed because children are sick with water-borne disease. Every 60 seconds a child under age 5 dies from a water-borne disease. These diseases can be easily prevented with the right resources and knowledge.

Studies have shown that even if every person drank safe water, the global burden of water-borne diseases would only be reduced by 21%. However, when safe water is combined with access to and improved latrine and handwashing with soap, then the incidence of water-borne diseases world-side would be reduced by at least 65%6.

6 Global Water Supply and Sanitation Assessment 2000 Report. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, 2000. - See more at: http://lifewater.org/process/strategy/#fn-1597-1

18 mWASH Manual Community Health and WASH Lesson 2.1 WASH-Related Disease Transmission

Lesson 2.1: WASH-Related Disease Transmission

Purpose of Lesson: • To learn about how WASH-related diseases are transmitted Objectives: • Discover pathways germs travel as they spread in communities • Learn ways to block disease pathways • Demonstrate ways diseases are spread in communities Materials: • Poster Set A: Disease Transmission • Poster Set B: Disease Blocking • String or branches for showing the transmission pathways • Optional: Flipchart and markers Preparation: 1. Determine the local terms for “diarrhea,” “feces,” and “germs.” 2. If possible, get statistics for the country you are in on the number of children under 5 that die every year from diarrhea. Also get statistics on the number of lives that can be saved through handwashing. You will use this in lesson 5. 3. Determine which optional activities to use in the lesson. 4. If doing the Drama Activity with designated actors: Choose two people to demonstrate how diarrhea can be passed from one person to another in a community. 5. Collect needed Poster Sets and materials. Time: 45-60 minutes

Background • Germs: o Germs are tiny and cannot be seen with the human eye. Some germs are found inside feces that can cause diarrhea and sickness if they get into someone’s mouth. o All feces, even animal feces, contain germs that will cause sickness. o Germs that cause diarrhea can enter someone’s mouth by traveling on our hands, on flies, on food, on animals, or in water. • Diarrhea kills around 1.8 million people worldwide every year. • Handwashing with soap is one of the easiest and most effective ways to block the spread of diarrhea. • Even if everyone in the world had access to safe drinking water, the global burden of water-borne diseases would only be reduced by 21%. When clean drinking water is combined with a basic latrine and adequate handwashing practices, incidence of water-borne diseases is reduced by at least 65%7

7 http://www.unicef.org/wash/files/gafull.pdf

19 mWASH Manual Community Health and WASH Lesson 2.1 WASH-Related Disease Transmission

1. How Diarrhea is Spread: 15 minutes

Introduction Learning Questions: • What do most people in the community believe causes disease? • Does anyone know what germs are or where germs are found? • Do you know of any ways that feces get into your mouths?

After the introductory discussion, use Poster Set A: Disease Transmission to show how the sickness of diarrhea is spread. Lay posters A9 (feces) and A2 (mouth) about two meters apart on the ground. Arrange posters A3-A8 in the order that is shown in the reference picture (A1). Use strings or sticks to show the pathways from the feces poster to the mouth poster that germs could travel to make someone sick. Show the participants one pathway that germs can travel. Let the participants complete the rest of the pathways. Leave this diagram on the floor for use later in the lesson.

Add in information from the Background section on germs and feces. • Do you think your community is eating feces in all these ways? • Which pathway is most common in your community?

2. Optional Activity: Drama About the Spread of Diarrhea: 15 minutes

Either have designated actors perform a drama for the rest of the participants, or break participants into groups and have each group create their own drama. Actors perform a drama about how the sickness of diarrhea can be passed along in the community.

Activity Questions: • What was happening in the drama? • What were some of the ways the sickness got passed along? • Does this happen in your community? • In what ways does this happen here?

20 mWASH Manual Community Health and WASH Lesson 2.1 WASH-Related Disease Transmission

3. Ways to Stop the Spread of Diarrhea: 15 minutes

Use Poster Sets A: Disease Transmission and B: Disease Blcoking to show how the sickness of diarrhea can be stopped from spreading. Make sure that Poster Set A is arranged correctly on the ground and connected by sticks or strings to show how germs are spread. By placing the posters from Poster Set B on top of the pathways, you can show how the spread of sickness can be stopped. Use poster B2 to demonstrate. Place poster B2 between the river and the mouth to show that boiling water can prevent germs in the water from entering someone’s mouth. Hand out the rest of the posters to the participants and let them complete blocking the pathways.

Activity Questions: • Can someone describe how each picture blocks the spread of sickness?

Discussion Questions: • How can picking one place to defecate, like in a latrine, help to block the spread of germs? • How can you stop animals from spreading germs? • How can you make sure no germs get on your food?

4. How Handwashing Effects Others: 5 minutes

Use the Bible verse below to explain how handwashing can affect others in your community. Either read the Bible verse out loud or write it on a large poster or flipchart.

“Love your neighbor as yourself. Love does no harm to its neighbor.” Romans 9b-10a (NIV-1984) Discussion Questions: • What do you hear in this verse? • What have you seen that can bring harm to us or to others? • How can you protect yourself and your neighbors from diarrhea?

21 mWASH Manual Community Health and WASH Lesson 2.2 WASH-Related Diseases

Lesson 2.2 WASH-Related Diseases

Purpose of Lesson: • To learn about different kinds of WASH-related diseases and how to prevent them

Objectives: • Learn characteristics of diseases related to unsafe water, not washing, or not using latrines Materials: • WASH-Related Disease Characteristics from Resource Packet • Poster Set B: Disease Blocking • Flipchart and Markers Preparation: 1. Determine which WASH-related diseases are most common in your communities and only teach these; do not use the materials and background information for diseases not common to your region. 2. Cut apart the appropriate WASH-Related Disease Characteristics. 3. Gather the necessary material from the resource packet 4. Make Flipchart

Time: 55 minutes

Background: • There are many diseases related to poor WASH habits: drinking or playing in unsafe water, not using latrines, or not washing. These are called WASH-related diseases. • Diarrhea can lead to death if not treated. • Diarrheal disease is one of the top 10 leading causes of death in the world, and the second leading cause of death in children under 5 years old. (World Health Organization) • People with diarrhea should drink more water to keep their bodies hydrated. • Scabies can be prevented by washing the body with safe water and soap. • Trachoma can be prevented by washing the face, especially, with safe water

22 mWASH Manual Community Health and WASH Lesson 2.2 WASH-Related Diseases

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • What are the most common diseases in this region? • Do you know of any diseases people often get because of the community’s water, sanitation, or hygiene behaviors?

2. WASH-Related Disease Characteristics: 20 minutes

Divide class into groups (the number of groups should match the number of diseases the lesson will focus on). Hand out one WASH-Disease card to each group. Ask the groups to read about the disease on their card and discuss the following questions:

• What body parts are affected? • Is this disease common in our community?

Give groups about 5 minutes to do these three tasks, and then ask each group to present its action and share its answers to the two questions above with the rest of the class.

Draw 4 columns across one or two pieces of flipchart. Label the columns: Diarrhea, Pneumonia, Blindness, and Death. As a class, list which diseases lead to which result.

3. WASH-Related Disease Prevention: 20 minutes

With people still in their same groups, Poster Set B: Disease Blocking from Lesson 2.1 to discuss which diseases could be prevented by practicing the WASH behaviors learned in the previous lesson. Hold up the first poster and ask groups to stand up and say the name of the disease on their card if the disease could be prevented by the WASH practice you are holding up. Continue through each of the disease blocking posters.

Finish by asking if there are any diseases on people’s cards that could not be prevented by any of the actions listed, and ask how that disease could be prevented (ex: malaria prevented through mosquito nets and removing stagnant water, scabies prevented by washing the entire body with safe water and soap, trachoma can be prevented by washing the face with safe water).

23 mWASH Manual Community Health and WASH Lesson 2.3 Diarrhea Care & Treatment

Lesson 2.3: Diarrhea Care & Treatment

Purpose of Lesson: • To learn how to help people who have diarrhea Objectives: • To learn symptoms of dehydration • To know what to do for someone with diarrhea • To know when to take someone to a health facility Materials: • Flipchart and markers • Symptoms of Severe Dehydration Requiring Visit to Clinic from Resource Packet Preparation: 1. Cut apart each of the Symptoms Requiring Visit to a Clinic and put them, folded, in a bowl 2. Post on one side of the room a sign that says, “TRUE” and on the other side of the room a sign that says, “FALSE” Time: 45 minutes Background8 • Definitions: o Diarrhea: The passing of loose, watery stools three or more times per day. o Dehydration: When the body loses the water and salts necessary for it to function properly, often through diarrhea or vomiting. • Signs of severe dehydration: o Weak and tired body o Sunken eyes, cheeks, or abdomen o No tears when crying o Very dark yellow urine or no urine o On an infant’s head, the soft spot is sunken • When to Get Help from a Hospital or Health Clinic o Diarrhea AND any of the following symptoms: o Displays signs of severe dehydration o Blood in their stools o Problems breathing o Infant is less than two months old o Vomits everything o High fever o Physically incapable of drinking o No improvement after 3 days o No or only partial consciousness **Note: Continue using the SSS or ORS solution until treatment at a clinic. • Diarrhea is a leading cause of death among children globally, and those in developing countries are the most at risk. Measures to prevent childhood diarrhea include increasing access to safe drinking

8 Information for background material adapted from TALC (teaching Materials at Low Cost) P.O. Box 49, St Albans, Herts, AL15TX, UK. and Kenya Institute of Education, Some Common Childhood Diseases and Health Records, Book 3 (Nairobi: Kenya Institute of Education, 2006) 12-19. and “ORS Solution: A Special Drink for Diarrhea.” FRESH Tools for Effective School Health http://portal.unesco.org/education/en/files/37769/11056656723FOL_ORS_Solution.doc/FOL%2BORS%2BSolution.doc (accessed 16 August 2011)

24 mWASH Manual Community Health and WASH Lesson 2.3 Diarrhea Care & Treatment

water and sanitation facilities, improving hygiene practices, promoting exclusive breastfeeding, rotavirus immunization, vitamin A supplementation, and zinc intake following a diarrheal episode. When prevention does not work and a person develops diarrhea, proper care should be taken so the individual does not become dehydrated and is able to recover quickly. • If not managed properly, diarrhea can have devastating consequences such as malnutrition and even death. The way diarrhea kills is through dehydration. Prompt actions can usually prevent dehydration and help the person recover. Additionally, zinc is important in helping a child recover from and prevent new episodes of diarrhea. Zinc decreases the length and severity of diarrheal episodes, and it also helps prevent a child from getting diarrhea again for the 2-3 months following treatment. • List of treatments for caretakers at the first sign of diarrhea: o Immediately begin giving increased amounts of appropriate fluids, including ORS or SSS, food-based fluids (e.g., soup, rice water, yogurt), or clean water o For breastfed children, continue and even increase breastfeeding o Increase feeding during and after the episode o Provide children with zinc supplementation o Avoid giving anti-diarrheal drugs or antibiotics, unless under the direction of a health care provider o Recognize the signs of dehydration and other issues requiring a visit to a health care provider

25 mWASH Manual Community Health and WASH Lesson 2.3 Diarrhea Care & Treatment

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • What are some of the ways we have learned to prevent diarrhea? • How might you be able to tell if someone is dehydrated? • Do people in your community usually treat dehydration? • What do you recommend for treating someone with dehydration? • What happens if dehydration is not treated?

Explain that, as we have already discussed, diarrhea is a leading cause of death among children globally, and that most of Lifewater’s work helps prevent diarrhea. However, it is also important to know how to treat diarrhea if someone has it, so that it does not lead to death. This lesson will focus on diarrhea care and treatment.

In many countries, prepared ORS packets are readily available and are the preferred method. However, in countries where ORS packets are not available, people can make their own sugar salt solution (SSS). Program staff should determine whether ORS packets are readily available in the communities. If not, they should plan to teach people how to make their own SSS. Instructions are in Appendix 2.

2. Preventing Dehydration Due to Diarrhea: 20 minutes

Have a sign that says, “True” on one side of the room and “False” on the other. Read the Activity Statements below, and have people move to the side of the room, depending whether they think the statement is true or false advice for someone caring for a person with dehydration due to diarrhea. After everyone has ‘voted’ you can choose to invite participants to explain why they voted that way, or simply tell them the correct answer and any applicable details.

Finish the activity by returning to seats and asking the Discussion Questions below. Summarize the most important points: 1) give someone with dehydration due to diarrhea ORS/SSS/Breast milk (if young child/infant), 2) give them more fluid than normal, 3) give them more or the same amount of food (not less).

Activity Statements: • Immediately begin by decreasing the amount of fluids given to the patient o FALSE: Immediately begin giving increased amounts of appropriate fluids, including ORS or SSS, food-based fluids (e.g., soup, rice water, yogurt), or clean water § How much fluid? • For children under 2, approximately 1/4 cup (50-100 ml) after each loose stool • For older children, 1/2 to 1 cup (200 ml) • For adults, 2 cups (500 ml) • If the patient vomits out the fluids, continue to give it to them o TRUE: Continue to have them take the fluids using small sips. The body will still absorb some of the fluids. • For breastfed children, increase the amount of breastfeeding o TRUE: For breastfed children, continue and even increase breastfeeding • Decrease feeding after the diarrhea episode o FALSE: Increase feeding during and after the episode • It is good to give children and infants with diarrhea Zinc supplements o TRUE: Provide children with 20 mg per day of zinc supplementation for 10-14 days § Infants under 6 months should receive 10 mg per day (1/2 a tablet)

26 mWASH Manual Community Health and WASH Lesson 2.3 Diarrhea Care & Treatment

• Give the patient any anti-diarrheal drugs or antibiotic you have available until you are able to talk to a health care provider. o FALSE: Avoid giving anti-diarrheal drugs or antibiotics, unless under the direction of a health care provider • Look for the signs of dehydration and other issues requiring a visit to a health care provider o TRUE

Discussion Questions: • Does anyone have a question based on that information? • Were any of the statements surprising? • Which of these practices is most common in your community? • Which of these practices is least common?

3. When to Get Help from a Clinic: 20 minutes

Explain that participants will now play a game in which they must try to remember the symptoms accompanying diarrhea that indicate a person should be taken to a health worker or clinic. Allow participants to briefly look in the background section at the list. Then make sure their books are closed and under their chairs.

Game Set-Up: The participants are seated in a circle, with Team A seated in one half the circle and Team B seated on the other half. Creatively choose one team to go first.

The Goal of the Game: To get the most points by guessing the correct symptoms indicating a person should be taken to a health worker or clinic.

Rules: A team has 45 seconds in which one person on the team will draw a symptom out of a bowl and will try to get the rest of the team to guess the symptom, following the rules of that round. As soon as the correct symptom is guessed (must be exact wording), the same person can draw another symptom from the bowl, until 45 seconds are up. Then the other team will then have 45 seconds to do the same. Turns go back and forth between teams, with new people selected each time, until all symptoms have been guessed. *If the person breaks the rules of the round, they must put that card back in the bowl and draw another.

Scoring: Scores are tallied after each round, one point per correctly guessed symptom.

Rounds (mixed-language): The first round, the person draws the symptom on a whiteboard or flipchart. The second round, the person acts out the symptom and cannot say any words or make any sounds. The third round, the person can only say one word per symptom. People guess based on that one word.

Rounds (single language): The first round, the person explains the symptom using any words except those written on the card. The second round, the person draws or acts out the symptom and cannot say any words or make any sounds. The third round, the person can only say one word per symptom. People guess based on that one word.

27 mWASH Manual Community Health and WASH Lesson 2.4 The Sanitation Ladder

Lesson 2.4: The Sanitation Ladder

Purpose of Lesson: • To learn that different levels of sanitation exist and that some locations and practices of defecation are better that others Objectives: • To describe the community’s sanitation situation • To introduce the sanitation ladder • To Identify options for improving sanitation • To discover that improvements can be made step by step Materials: • A stack of blank, normal sized pieces of paper • A flipchart • Markers (enough for all participants) • Poster Set C: Sanitation Ladder Preparation: 1. Gather and prepare all necessary materials. 2. Learn which latrine types are common in the area and which latrine types would be appropriate. 3. Optional: Write Deuteronomy 23:12-14 on a flipchart. Time: 80 minutes

Background • A sanitation ladder is a visual tool that aims to help people identify options for improving sanitation in their community and realizing that this process can be gradual. • Parts of the sanitation ladder: o Open defecation is a term used for when people relieve themselves in the open and leave the feces lying on the ground. When feces are left in the open, it can get on animals, humans, or flies, and can make you sick. o The Dig and Bury method is an easy way to dispose of feces. § A location that is right for burying feces is in dirt that is not very hard, located away from houses or cultivated fields and at least fifteen meters away from a water source. § One must bury feces twelve to sixteen centimeters under the surface or else people, animals or heavy rains may uncover it later. The hole should not be deeper than this or else the feces may not decompose properly. § After defecating in the hole, use organic compostable material to wipe oneself (e.g. leaves). After this is finished, cover the feces and wiping material with dirt and pack the dirt down. § Biblical reference to this method: “Mark out an area outside the camp where you can go to relieve yourselves… After you relieve yourself, dig a hole with a stick and cover your excrement… Keep your camp holy; don’t permit anything indecent or offensive in God’s eyes.” - Deuteronomy 23:12-14 o Unimproved Latrines are facilities that don’t effectively prevent contact with feces. A traditional latrine is another name for an unimproved latrine. Traditional latrines do not have a slab or a platform. They may or may not have walls, a roof, or a door. § Parts of a traditional latrine: • The Pit: The pit is where feces and urine go. All pits should be partially lined to stop the pit from collapsing.

28 mWASH Manual Community Health and WASH Lesson 2.4 The Sanitation Ladder

o Improved Latrines are facilities that prevent human contact with feces. The most common types of improved latrines are: § Pit latrines with a slab- The pit is completely covered by a slab or platform usually made out of cement or mud that has a squatting hole or seat to let the feces through. The slab should be surrounded by a shelter to provide privacy and covered by a roof. It is good for the squatting hole to remain covered when not in use to reduce smell and flies. The hole must have a cover to keep flies from spreading disease. § Pour-flush latrines- These latrines need water to “flush” the feces down into the pit. Flushing down the feces reduces the smell and amount of flies in the latrine. This latrine type is not good in regions that don’t have easy access to water. § Ventilated Pit Latrine (VIP)- This type of latrine is similar to a pit latrine with a slab, however, VIP latrines have a ventilation pipe that reduces odor and flies inside the latrine. § Composting latrines- These latrines break down the feces into harmless material. After each use, you must add leaves, ash or soil to the pit in order to help in the composting process. Once the feces break down, it can be used as a fertilizer for crops. These latrines are useful in farming areas or when the water table is high.

29 mWASH Manual Community Health and WASH Lesson 2.4 The Sanitation Ladder

1. Drawing Local Practices: 15 minutes

Explain that we will now switch to learning how to prevent diarrhea.

Divide the participants into groups of three to four people and give each group a stack of blank paper. Instruct groups to discuss as a team different types of places that people defecate in the local communities. Have groups use the paper they were given to draw each defecation place. After a few minutes, ask participants to return to the circle but sit together with their group.

Facilitate a discussion using the Activity Questions below. Have participant groups look through their drawings and hold up the one that answers the question.

Activity Questions: • Which of these drawings represents the most common practice in this region? • Which drawing represents the best place to defecate? o Why is this the best? • Which drawing represents the worst place to defecate? o Why is this the worst?

2. Introduce the Sanitation Ladder: 5 minutes

Draw where the class can see a simple ladder with the ground underneath and with 3 rungs. Make sure there is space between each rung. Read the definition of the sanitation ladder.

A sanitation ladder is a visual tool that aims to help people identify options for improving sanitation in their community and realizing that this process can be gradual.

3. Open Defecation: 5 minutes

Label the ground below the ladder, “Open Defecation” and tape Poster C1 next to it.

Use the facilitation questions below and the drawings groups made to start a conversation about open defecation. This will provide a general idea of what the community already knows about the effects of open defecation. After the discussion, use the information in the Background section about open defecation to add information that the participants might not know.

Introduction Learning Questions: • What is open defecation? • Does anyone in your community practice open defecation? (ask groups to show pictures they drew that represent open defecation practices) • What do people like about open defecation? • What do people not like about open defecation?

30 mWASH Manual Community Health and WASH Lesson 2.4 The Sanitation Ladder

4. The Dig and Bury Method: 10 Minutes

Label the first rung, “Dig and Bury” and tape Poster C2 next to it.

Ask if anyone has heard of this method, and if so, what they know or what they think it may be. Fill in with information from the Background section, including the verse from Deuteronomy. Do so in a participatory manner, using questions instead of listing all the steps.

Discussion Questions: • Are there any questions about this method? • What is good about this method? • What is not good about this method? • Do people in your community practice this method? Why or why not? • How would using this method improve the health of a community currently practicing open defecation? • How can teaching Deuteronomy 23: 12-14 in a community change their perspective on open defecation?

5. Unimproved Latrines: 10 minutes

Label the second rung, “Unimproved/Traditional Latrine” and tape Poster C3 next to it.

Ask if anyone in their communities defecates in a latrine that doesn’t have a solid slab. Introduce the basic concept of an unimproved/traditional latrine using the points in the Background section.

Explain that since unimproved latrines have no slab or platform, contact with feces is still possible. Sickness can still occur when using unimproved latrines. Select groups’ drawings that show this type of latrine and ask them to show participants.

Discussion Questions: • How would this method improve the health of a community currently practicing the Dig and Bury method? • Are there any other advantages of this method over Dig and Bury?

6. Improved Latrines: 10 minutes

Label the third rung, “Improved Latrine” and tape poster C4 next to it.

Ask if anyone in the communities use a latrine that has a solid, cleanable slab, and to show any drawings that represent an “Improved Latrine”. Begin a discussion about what types of improved latrines exist in the community. Use the information from the Background section on the types of latrines that exist in the community to answer any questions about them participants may have.

Do not introduce new types of latrines. The purpose of this lesson and this course is to introduce the concept of the sanitation ladder the pros and cons of different types of latrines already present in local communities. All further discussions of how to construct a latrine and what type of latrine is best for the region should be handled separately and in more

31 mWASH Manual Community Health and WASH Lesson 2.4 The Sanitation Ladder detail. (Tape up poster C5 and discuss components if the participants bring up Ventilated Improved Latrines)

Discussion Questions: • How is an improved pit latrine different from an unimproved/traditional latrine? • How does an improved latrine reduce sickness? • Are there other benefits to an improved latrine? If so, what?

7. Moving Up the Ladder: 25 minutes

Further explain the concept of the sanitation ladder making sure to highlight these points: • Moving up the sanitation ladder, one can improve their sanitation practices and health. • Improving their sanitation can be a gradual process of slowly moving up the ladder.

Break the class into three groups. Assign each group one of the following sections of the sanitation ladder: • Open defecation to Dig and Bury • Dig and Bury to Unimproved Latrine • Simple Latrine to Improved Latrine

Give each group a piece of flipchart paper, and ask them to answer the following questions: • What resources might it require for someone to move from one step of the sanitation ladder to the next? • How long might this take? • Would this be easy or hard? Why?

Have each group share their findings. Then, discuss the following questions.

Discussion Questions: • Would you recommend that families stay at their current step until they have enough resources to get straight to the top? Why or Why not? • What small steps could they take to improve their situation?

Go through each rung, and have the group brainstorm smaller steps families could take to improve their situation. As the group responds, add rungs in between each sanitation step on the ladder. This shows that even smaller steps can help families improve their situations.

8. Possible Questions for Community Members:

• What are the advantages of your type of sanitation facility? • What are the disadvantages of your type of sanitation facility? • What latrine type would you like to use in the future? • What are some of the obstacles you might have in building this latrine type? • What are some ways you could overcome these obstacles?

32 mWASH Manual Community Health and WASH Lesson 2.5 Cleaning Latrines

Lesson 2.5: Cleaning Latrines

Purpose of Lesson: • To learn how to properly clean a latrine Objectives: • Review how to properly clean a latrine • Practice cleaning a latrine Materials: • If doing step 4: o Long-handled brush o Water and soap, or ash o Bag for trash o Way to wash hands after cleaning latrine Preparation: 1. Gather all necessary materials. 2. Determine the type of latrine used in the community. If latrines with a concrete slab are used, teach the steps for cleaning a cement slab. If latrines without cement slabs are used, teach the method for cleaning latrines without a cement slab. 3. Determine if there is a latrine nearby that can be used for step 5. If not, use the optional activity. 4. Optional: Depict a latrine slab on the floor out of tape, string, sticks, etc. Time: 55 minutes

Background • Using a latrine is the most effective way to limit contact with feces. • Properly cleaning a latrine often will reduce the amount of smell and flies. • Putting ash or lime into the pit after each use will help to reduce the smell. • Trash should be swept out and placed in a pile outside the latrine for burning. Trash should not be thrown down the latrine into the pit. Throwing trash into the latrine will fill the pit faster and will attract more flies and animals. (See Cleaning Step 1) • If no soap is available, ash can be mixed with water for cleaning cement slabs (See Cleaning Step 2) • Long-handled hard brushes help effectively and safely cleaning latrines. The long handle keeps people from bending low close and risking contact with feces. Hard brushes most effectively scrape off things stuck to the slab. If these are not available, use what can be found locally. (See Cleaning Step 2)

33 mWASH Manual Community Health and WASH Lesson 2.5 Cleaning Latrines

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • What are some reasons people don’t use latrines? • What are common complaints you hear about latrines?

2. Cleaning Latrines with Cement Slabs: 10 minutes

If the community has latrines WITH a cement slab, use this section to teach participants how to properly clean a latrine with a cement slab.

Explain that we will be learning a simple and effective way to clean a latrine. As you describe each step in cleaning a latrine act it out and have participants stand up and act out the step with you. Use the Activity Questions in each step to draw out the understanding of the purpose of the step. Refer to the Background section for answers to the questions.

1. The first step of cleaning a latrine is to remove all the trash that is inside the latrine structure. Have participants act out sweeping trash down into the pit.

Activity Questions: • What are some negative results of people using the latrine like it is a rubbish pit and throw rubbish in the latrine frequently? • What are the risks of picking up trash to burn or bury instead of sweeping it down into the pit?

2. The second step is preparing soapy water to clean the slab with. Fill a bucket with water, add soap and mix the water. Pour this soapy water from a bucket onto the floor of the latrine. Scrub the floor with a long handled, hard brush. Start at the back of the latrine and move towards the front. Have participants act out this step.

Activity Questions: • What would you recommend mixing with water if no soap is available? • Why a long-handled hard brush?

3. Next, rinse the soap off of the slab by pouring clear water on the floor. This will keep germs from being swept to the back of the latrine. Have participant act this step out.

Activity Questions: • What do you think is the last step? • Why?

4. The last step is to wash your hands thoroughly with soap and water. This will ensure you do not get sick by any feces you may have been in contact with during cleaning.

3. Cleaning Latrines without Cement Slabs: 10 minutes

1. The first step of cleaning a latrine is to remove all the trash that is inside the latrine structure by sweeping it down into the pit. Have participants act out sweeping trash down into the pit.

34 mWASH Manual Community Health and WASH Lesson 2.5 Cleaning Latrines

Activity Question: • What are some negative results of people using the latrine like it is a rubbish pit and throw rubbish in the latrine frequently? • What are the risks of picking up trash to burn or bury instead of sweeping it down into the pit?

2. Next, sprinkle ash on the floor of the latrine and let it rest for a few minutes in order to kill all the germs and dry up the urine. Use a long handled, hard brush to sweep the extra ash into the pit. Sweep from the back to the front. This will keep germs from being swept to the back of the latrine. Have participants act out sprinkling ash and brushing from back to front.

Activity Question: • Why a long-handled hard brush? • What do you think is the last step? • Why?

3. The last step is to wash your hands thoroughly with soap and water.

4. Cleaning Schedule: 5 minutes

Use the questions below to facilitate a discussion on how often a latrine should be cleaned and by whom.

Discussion Questions: • How often do you think a latrine should be cleaned? • Who should clean the latrine? Why?

5. Optional Activity: Practice Cleaning a Latrine: 20 minutes

Take the class out to a nearby latrine. Have the group take turns cleaning the latrine.

Discussion Questions: • Are there any questions about the steps for cleaning a latrine? • What is beneficial about cleaning your latrine like this? • Do people clean latrines like this in your community? Why? Why not? • What can be done to address these barriers?

6. Optional Activity: Latrine Dance: 20 minutes

Divide the class into small groups. Have the groups create a song and dance that demonstrates how to clean a latrine. Give groups time to prepare, and then have them share with the class. Afterwards, ask the discussion questions from step 6.

Discussion Questions (if not asked in Optional Activity #5): • Are there any questions about the steps for cleaning a latrine? • Do people clean latrines like this in your community? Why? Why not? • What is beneficial about cleaning your latrine like this? • What can be done to address these barriers?

35 mWASH Manual Community Health and WASH Lesson 2.6 Handwashing at Critical Times

Lesson 2.6: Handwashing at Critical Times

Purpose of Lesson: • To understand the importance of washing hands at the four critical times Objectives: • To analyze the four critical times to wash hands • To identify real-life situations that fall under the four critical times to wash hands Materials: • Poster Set D: Before • Poster Set E: After • Optional: Flipchart and markers Preparation: 1. Create four labels for the four critical times to wash hands: a. After defecation b. After contact with child’s feces c. Before eating d. Before handling food 2. Cut Poster Sets D and E in half so each image is a separate half sheet of paper. 3. For the Drama Activity: Choose four participants to demonstrate how germs from feces can be spread from person to person. 4. Optional: Write the Bible verse used in step 5 on a flipchart or large piece of paper. 5. Collect needed Poster Sets and materials. Time: 60 minutes

Background • The two categories for handwashing are after contact with germs and before contact with food. • Washing your hands at these two times stops the spread of diarrhea directly after you come into contact with feces and prevents germs from entering your when handling food. • There are four critical times for handwashing, which fall into the two categories above. The most critical times to wash hands are: o After defecation o After contact with a child’s feces o Before eating o Before handling food • There are other times when it is good to wash hands, but handwashing at these four critical times will have the biggest impact on health. • Even though your hands might look clean, there may be tiny germs on them that you cannot see. • Children’s feces contain more germs and are more dangerous to people’s health than adult feces.

36 mWASH Manual Community Health and WASH Lesson 2.6 Handwashing at Critical Times

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • Do most people in your community wash their hands? • When do they usually wash their hands?

2. Brainstorm Handwashing Before and After: 15 minutes

Introduce the concept of washing hands before some things and after others. The before and after concept is one way people can remember the important times to wash hands.

Show the class Posters D1 (“before” label) and E1 (“after” label) and place them on the ground in the middle of the circle.

• What are examples of times we should wash hands before contact with food? • What are examples of times we should wash hands after contact with feces?

3. Introduce the Four Critical Times: 20 minutes

Introduce the four most critical times to wash hands. As you mention each, lay each label down on the ground. 1. Before eating 2. Before handling food 3. After defecation 4. After contact with a child’s feces

Pass out the Poster Sets D and E to the class. You may want to keep one poster to use as an example for the class. Have each participant describe his or her poster for the group, and then place it under one of the four labels or to the side if it is not one of the four categories. Help participants if they have trouble placing a poster.

Discussion Questions: • Why do you think these are considered the four most critical times to wash hands? • When might it be hard to wash hands at these times? Why? • What could be done to help us wash hands at these critical times?

4. Drama About How Germs Spread: 10 minutes

Choose a few participants to perform a drama about one way germs in feces can spread from participant to participant.

37 mWASH Manual Community Health and WASH Lesson 2.6 Handwashing at Critical Times

Have the actors perform the same drama a second time. This time when the audience sees an actor doing something that they should wash their hands before or after, call out “Wash your hands with soap!” Pause the drama while the actor pretends to wash their hands with soap. Then, ask for a volunteer to explain why they should wash their hands.

Discussion Questions: • Why did the actors get sick the first time the drama was performed? • What made the difference in the actor’s health in the drama this time?

5. The Bible’s Message on Handwashing: 10 minutes

Use the Bible verses below to show participants that God cares about showing loving to each other through washing our hands. Read both Bible verses aloud or write them on a large poster or flip chart.

“Love your neighbor as yourself. Love does no harm to its neighbor.” Romans 13:9b-10a (NIV-1984)

“Each of you should look not only to your own interests, but also to the interests of others.” Philippians 2:4 (NIV-1984)

Discussion Questions: • What do you notice in these verses? • What have you learned so far in this training that can help you practice love towards yourself and others? • [Think to yourself] What are some times to wash your hands that you are not currently doing very often? • [Think to yourself] How will you make sure to wash your hands at this time from now on?

38 mWASH Manual Community Health and WASH Lesson 2.7 Effective Handwashing

Lesson 2.7: Effective Handwashing

Purpose of Lesson: • To learn how to wash hands correctly and how using soap helps to prevent the spread of disease Objectives: • To learn how soap removes germs • To practice the steps for effective handwashing • To learn how to make a Tippy Tap Materials: • Sticky material that will stick to hands but can be rubbed off such as tape • A Tippy Tap, soap, and water for the handwashing demonstration • Watch or timer • Optional: Flipchart and markers • Materials for making a Tippy Tap (Gather enough material for 3-4 Tippy Taps): o Medium size clean jug (or other one to four liter container), with cap o Small plastic water bottle (one-half to one liter) or equivalent o String (nylon, plastic, cotton, or twine) o Piece of soap o Nail - to melt holes in container and soap cover o Candle (and matches) to heat nails o Pliers to hold nail (or small cloth to protect fingers from hot nail) o Small wire used to help pull string through holes in the container o Knife or scissors to cut top off the small plastic water bottle o Pen or pencil to mark holes on container Preparation: 1. Collect all needed materials to make the Tippy Tap. 2. Make a Tippy Tap to use for demonstration. 3. Fill Tippy Tap with water and make sure it has soap for handwashing demonstration. 4. Optional: Write handwashing steps on a flipchart Time: 75 minutes

Background • Handwashing with soap and water is the most effective way to block the spread of disease. • Using water alone will not remove all of the dirt and germs from your hands. • Using soap and water works the best because it loosens the germs from your hands and allows water to wash these germs away. • There are other substances besides soap that can be used to wash your hands. These include ash, sand, soil, some plant material, and sometimes lemon. Studies show that mud and ash are as effective as soap in reducing germs9 and that the main determinants are washing both hands, rubbing hands together, and the amount and quality of water used for rinsing10.

9 Hoque BA, Briend A Community Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka.The Journal of Tropical Medicine and Hygiene [1991, 94(1):61-64]

39 mWASH Manual Community Health and WASH Lesson 2.7 Effective Handwashing

• Tippy Tap Overview: A Tippy Tap is a simple object that allows people to easily wash their hands using only a small amount of water. It is inexpensive and can be made using simple materials and tools. The Tippy Tap can be made from any container of about one to four liters capacity. A jug with a handle works best, but a Tippy Tap can be made from any plastic container, even a two-liter bottle. • Directions on how to make a Tippy Tap – Reference the Tippy Tap Diagrams Appendix 3: 1. Use pen to mark three holes on container (see diagram for location): 2. Heat the nail using the flame from the candle and push it through the plastic container where you have marked the holes. 3. Make the soap cover by cutting the bottom off of the small plastic bottle. Make a hole in the center using the heated nail. 4. Cut three pieces of string (if nylon or plastic, melt string over candle). o One piece - one and one-half meters long (hanging string) o Two pieces - each one-half meter long (pull string & soap string) o Alternate: You may make the pull string long enough to reach the ground with an additional half-meter to tie a “foot loop.” 5. Put the longer hanging string through the two holes in upper back of the container using the small wire if necessary. You may knot the string at each side of container to keep string from sliding out. 6. Put one end of the pull string around the neck of the container and tie a knot. Tie a loop on the other end of the string large enough to fit a hand through. (If you are making a “foot pull string”, then make the loop big enough to slip a foot in or tie it to a rock so you can push your foot down on the string.) 7. Put a hole in the piece of soap using the nail. Tie string to soap. Put other end through soap cover and tie to the Tippy Tap “hanging string.” 8. Hang Tippy Tap from tree branch, roof or other support. 9. Fill Tippy Tap 2/3 full with water and replace cap. • How to use a Tippy Tap: 1. Use the pull string to tip container and wet hands. Then release the string. 2. Use the soap and wash hands well. 3. Use the pull string to tip container and rinse hands. 4. Let hands air dry or dry with a clean cloth. • There are six steps for effective handwashing. 1. Wet your hands with water. Clean flowing water removes dirt and germs most effectively. 2. Add soap. Other substances besides soap can also be used like ash, sand or local plants. 3. Rub your hands over each other for 20 seconds. The rubbing action helps to remove more dirt and germs. 4. Clean between fingers and under nails. Dirt and germs often hide in these places. 5. Rinse hands with clean flowing water. This allows germs to slide off your hands. 6. Dry your hands. Shake them in the air. Do not wipe your hands on your clothes because this put germs on your hands again.

10 BA Hoque International Journal of Environmental Health Research, Volume 13, Supplement 001, 2003

40 mWASH Manual Community Health and WASH Lesson 2.7 Effective Handwashing

1. What Makes Handwashing Effective: 10 Minutes

Introduction Learning Questions: • Does anyone in your home use soap? o If no, does anyone in your community use soap? o If yes, what do they use soap for? • Why do they use soap instead of only water?

Demonstrate why soap makes handwashing more effective at blocking the spread of disease. Crumple up pieces of tape and stick them on your hands to represent germs. Pretend to wash your hands with water and allow a few of the tape pieces to fall off. Then pick a volunteer to play the part of “soap.” Instruct this person to pick off all the remaining pieces of tape from your hands.

Discussion Questions: • Why is washing your hands with soap and water better than just using water? • Are there any other reasons you may want to use soap? [Some people like using soap because it makes them smell nice and makes their hands soft] • What other substances do you know of, besides soap that can be used to wash hands?

2. Tippy Tap Introduction: 5 Minutes

Introduction Learning Questions: • What type of device do people use to wash their hands in your community? • Do you think more people would wash their hands at critical times if they had a place for handwashing outside their latrine or near their kitchen? • Have you heard of a Tippy Tap before? • Have you seen a Tippy Tap being used in your community?

Use the introduction questions below to assess what participants already know about tippy taps. Show participants the example Tippy Tap you prepared. Before providing any information, ask participants questions such as those below to help them deduce what a Tippy Tap is, what its benefits are, and what materials are required to make one. Then fill in the information they deduce with Tippy Tap Overview information in the Background section.

If no one mentions it, explain that a Tippy Tap does not allow a person to reuse the water, so it is safe than many other devices. It also has soap attached and can be filled with water so that all the materials needed to practice proper handwashing are present.

Activity Questions: • Does anyone know what to do with this? Can you show us? • What stands out to you about it? • Does anyone have an idea what the benefits of using this device for handwashing are? • What materials are needed to make this?

41 mWASH Manual Community Health and WASH Lesson 2.7 Effective Handwashing

3. Making a Tippy Tap: 45 Minutes

Demonstrate to participants how to make a Tippy Tap by following the directions in the Background section above. Use the image of the Tippy Tap found in Appendix 3 to help with this. Break participants up into small groups and allow them to make their own. Demonstrate each step, then, have participants to repeat the step on their own. While participants are making their Tippy Taps, all facilitators walk around and provide help if a group needs it.

4. The Six Steps for Effective Handwashing: 10 Minutes

Introduction Learning Question: • What do you think are the most important things to teach when teaching others to wash hands?

Explain that Lifewater teaches six steps of handwashing. These can be found in the Background section above. Go over the steps. Use the Tippy Tap you made to demonstrate the six steps. Have a volunteer or facilitator act out the steps while you read and explain each step.

Activity Questions: • Who can demonstrate all six steps without looking at the written list? • Which step do people in the community most often miss? • What can you do to help them remember this step? • How will practicing these steps help reduce sickness in your community? • Do you know how long twenty seconds is?

To demonstrate how long twenty seconds is, have a timer and time twenty seconds. Have participants close their eyes and raise their hands when twenty seconds has passed. Wait until most participants have raised their hands, then, tell them the range of their guesses (ex: ten seconds to forty seconds). Then time it again and tell them when twenty seconds is up. Have participants think of a creative way to teach others how long twenty seconds is without a timer.

42 mWASH Manual Community Health and WASH Lesson 2.8 Making Water Safe

Lesson 2.8: Making Water Safe

Purpose of Lesson: • To learn simple ways to make water safe to drink Objectives: • To learn how to make water safe • To consider how God and water cleanse us in different ways Materials: • Three clear containers that can be seen through • Cooking pot with lid • Bucket with lid • Clean, tightly woven piece of cloth that is large enough to cover the cooking pot • Rope to tie around the opening of a water container (two to three feet) Preparation: 1. Collect water from three different sources in clear containers: one is from a dirty source so that the water looks very dirty, one is from an unsafe source that looks clear, and one is from a safe water source. 2. Find out the common methods for water purification in the community. Teach these methods as well as one or two other methods that the participants may not know. Make sure this method is appropriate for the region. Collect the materials that are used for these methods. 3. Make sure this method is appropriate for the area. If wood or other cooking fuel is scarce in the area, this method may not be appropriate. 4. Determine which optional lesson to teach. 5. Gather all necessary materials. 6. Optional: Write the bible verse on a flipchart or large piece of paper. Time: 60 minutes

Background • Unsafe Water: has germs, which make us sick and cause disease. Many of the germs cannot be seen with our eyes. • Safe Water: comes from a protected source or is treated to remove germs. It is good for our body and keeps us healthy. • Water from boreholes and protected springs is usually safe but can become contaminated and require treatment. • We cannot tell by looking at water whether it is safe for drinking and cooking. We must look at the source of the water. • Sealed water sources are good, surface water sources are not. • Some ways to make unsafe water safe is through boiling water, filtering water, the Water Guard Method, the PuR Method, and the SODIS Method. • When using methods that include chemicals, make sure to follow the directions on the packet. If these directions are not followed, the chemicals can make you sick. • The Boiling Method: o Very effective in removing and destroying most of the small organisms, which cause water borne diseases. It also can produce large quantities of safe water at one time. o One disadvantage with this method is the problem of deforestation or lack of available fire source and the possibility of burns while boiling. The World Health Organization estimates that it requires one kilogram of wood to boil one liter of water11. In some areas this method is simply not possible.

11 http://www.who.int/water_sanitation_health/dwq/wsh0207/en/index4.html

43 mWASH Manual Community Health and WASH Lesson 2.8 Making Water Safe

o Water should come to a rolling boil (large bubbles continuously coming to the surface of the water). Once water has reached this boiling point, the pathogenic bacteria, viruses, and protozoa are adequately killed12. Lifewater recommends boiling for 1 minute to be sure the water has reached a sufficient temperature. o Cover pot and let cool to room temperature. • Safe water should also be used when possible for cleaning dishes, vegetables, cooking, and washing hands. • Water containers used for storage can become re-contaminated if the storage time is longer than a week. Wash or change storage containers often. Store the water in a dry, cool place away from sunlight and heat.

12 http://www.who.int/water_sanitation_health/dwq/Boiling_water_01_15.pdf?ua=1

44 mWASH Manual Community Health and WASH Lesson 2.8 Making Water Safe

1. Introduction Learning Questions: 5 Minutes

Show the class the three containers of water you have prepared. Use the questions below to start a conversation with participants about safe or unsafe water.

Discussion Questions: • What do you notice about these containers? • Which containers do you think are safe for drinking and cooking? Why? • Do you know for sure whether this water (in the unsealed bottle) is safe?

Explain that safe water is sealed and/or protected and unsafe water is most often unprotected/unsealed. Therefore, to know whether water is safe or unsafe, one must know the source of the water. Uncover and read the description of safe and unsafe water written on the flipchart. Share with the participants what kind of water is in each container. Be sure to share some of the information from the Background section. Then ask participants the Introduction Learning Questions below.

Introduction Learning Questions: • Do you know any ways to make your water safer to drink? o If so, can you describe what you do? o Is this method of water treatment common in your community? • Do you know of any other ways to make water safe to drink? • What are the most common methods of making water safe to drink in your community?

2. Filtering and Boiling Water: 25 Minutes

The facilitator or a participant acts out each step while the facilitator describes the step. All other participants mimic the actions. Before reading each step, use questions to give participants the opportunity to share their knowledge, either of what the step might be, why it is important, or what materials are necessary for that step.

Introduction Learning Questions: • Do you know anyone who filters or strains his or her water to make it safer for drinking? o How might this make it make it safer? • Do you know anyone who boils his or her water to make it safe for drinking? o How might boiling the water make it safer?

Next, use the materials to demonstrate how to boil water. Take the bucket with the lid and pretend to fill it up with water. Tell participants that it is ideal to let this water sit for a long period of time in order to let all of the dirt and germs settle to the bottom.

The cooking pot can be prepared by placing the cloth over the top of the pot and tying the rope around the mouth to fasten the cloth. Then, the settled water can be poured into the cooking pot. When pouring, make sure to demonstrate that you should pour most of the water into the pot except for the water at the bottom that contains the settled material.

Next, carefully remove the cloth from the cooking pot as to not get any of the germs or dirt left on the cloth back into the water.

45 mWASH Manual Community Health and WASH Lesson 2.8 Making Water Safe

In order to remove all the germs your eyes cannot see, the water now must be boiled. Pretend to build a fire with firewood and place the pot of water over the fire.

Pretend to let the water boil for one minute. Let the water cool, then, transfer the safe water into a clean, narrow-mouthed container.

Discussion Questions: • Do you have any questions about boiling water? • Do people usually boil water in this way in your community? • Does anyone not boil water at all or in this way? o Why do you think people don’t practice this?

3. Optional: Additional Water Treatment Methods: 25 Minutes

After teaching this method, teach several other water purification methods that are appropriate for the area. These can be found in Appendix 4. Do not teach PUR or Water Guard if it is not locally available. Teach SODIS if appropriate, found in Appendix 5. Teach these additional water treatment methods in the same participatory manner as filtering and boiling- using actions, questions, and actual demonstration if possible.

46 mWASH Manual Community Health and WASH Lesson 2.8 Making Water Safe

4. How God Can Make Us Pure: 5 Minutes

Use the two Bible verses below to teach how just like dirty water can make us sick, an unclean heart can also make us sick. An unclean heat comes from sinning. Tell the participants how God can make our hearts pure. Read the Bible verse aloud or write it on a large poster or flip chart.

“God, create a pure heart in me. Give me a new spirit that is faithful to you.” - Psalms 51:10 (NIRV)

“But God is faithful and fair. If we admit that we have sinned, he will forgive us our sins. He will forgive every wrong thing we have done. He will make us pure.”

I John 1:9 (NIRV)

Discussion Questions: • What makes someone’s heart dirty? • How can someone make his or her heart clean again?

47 mWASH Manual Community Health and WASH Lesson 2.9 Keeping Water Safe

Lesson 2.9: Keeping Water Safe

Purpose of Lesson: • To learn how safe water can become unsafe and how to prevent this Objectives: • To learn how water can become unsafe • To learn how to prevent water from becoming unsafe Materials: • Poster Set F: Keeping Water Safe Preparation: 1. Determine if you wish to include the optional activity in the lesson. 2. If doing the Drama Activity: Pick 3-6 participants to demonstrate some ways that safe water can become unsafe during water collection, transportation, storage or use. 3. Collect all needed Poster Sets. Time: 50 minutes

Background • The safe water chain describes the four stages at which water from a safe source can become unsafe: 1) collection, 2) transportation, 3) storage, and 4) use. • You can prevent safe water from becoming unsafe by using clean, narrow-mouthed containers, covering open water containers, keeping animals away from the water source, not directly reaching into the water container, keeping utensils used to scoop water clean and washing hands before touching water containers. • Only through changing the way you collect, transport, store, and use water can safe water remain uncontaminated. • A narrow-mouthed container prevents the contamination that occurs when people dip used cups into wide-mouthed buckets or containers, thus contaminating the entire bucket/container13. • Originally safe water can become contaminated if it is stored too long in a closed tank. Bacteria and viruses can continue to grow in containers once they have been cleaned. Clean storage containers and replace water every one to two weeks.

13 http://www.who.int/household_water/research/safe_storage/en/

48 mWASH Manual Community Health and WASH Lesson 2.9 Keeping Water Safe

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • Is the water you drink safe or unsafe? • How do you know if it is safe or unsafe? • Do you know of any ways that safe water can become unsafe?

2. How Safe Water can Become Unsafe: 10 minutes

Show participants Poster F1 and ask the participants if the water being collected is safe to drink when it comes out of the well. Then show Poster F4. Ask the participants how the water could have become unsafe from the time it came out of the well to the time the child drank it. Then lay down F2 and F3. Use Posters F1-F4 in sequence to show the four stages during which safe water can become unsafe.

Discussion Questions: • Can you think of any other ways that safe water can become unsafe during each stage of the safe water chain? • After learning how water can become unsafe, do you think the water you have at home is safe or unsafe?

3. How to Prevent Safe Water from Becoming Unsafe: 15 minutes

Show Poster F5 of the narrow-mouthed container to the group. Lead a discussion with the group on how using a water container with a narrow mouth prevents water from becoming unsafe.

After this discussion, divide participants into groups of two to three people. Give each group one or two posters from F6-F11. Have each group discuss together what their picture shows and whether or not it represents a safe or unsafe practice. After a few minutes, ask each group to share what their picture shows and what they discussed. Have the group place their poster in the middle of the circle when they are done sharing.

Discussion questions • Which of the four stages of the safe water chain do you think is bringing most contamination in the community? • What can we do to change this behavior into a safe behavior?

4. Changing Behaviors: 10 minutes

Divide participants into six groups. Give each group one of the posters F5-through F10. In groups, ask the participants to discuss what obstacles community members might face when trying to use the method shown on their poster as well as how these obstacles might be overcome. Give the groups five minutes to discuss. Ask each group to share what they discussed.

Discussion Questions: • Are there any other suggestions for obstacles that you face? • Are there any other suggestions for ways to overcome these obstacles?

49 mWASH Manual Community Health and WASH Lesson 2.10 Keeping Food and Utensils Clean

Lesson 2.10: Keeping Food and Utensils Clean

Purpose of Lesson: • To learn why keeping food and utensils clean is important for health Objectives: • Distinguished between good and bad ways to handle food and utensils Materials: • Poster Set G: Clean Food & Utensils Preparation: 1. Gather all necessary Poster Sets. Time: 50 minutes

Background • We do not usually use soap14 on fruits and vegetables because soap doesn’t taste good and is not healthy to eat. Instead, fruits and vegetables can be scrubbed hard to remove germs. Fruits and vegetables are less sensitive than our hands so can be scrubbed hard enough to remove most germs unlike hands, which need soap. • Fruits and vegetables often come from places where human or animal feces are present. In order to make sure food is clean and free of germs, it is important to wash fruits and vegetables with safe water before eating them15. • We should not be afraid to encourage others in good health habits. • Drying racks are important because: o Drying dishes or containers in the sun kills all the germs. o They keep clean dishes away from dirty animals. o Clean dishes stop the spread of spread disease. § Reducing the number of flies § Reducing the chance for mold to grow

14 http://www.fda.gov/Food/FoodborneIllnessContaminants/BuyStoreServeSafeFood/ucm114299.htm#prep 15 http://www.who.int/dietphysicalactivity/publications/fruit_vegetables_report.pdf

50 mWASH Manual Community Health and WASH Lesson 2.10 Keeping Food and Utensils Clean

1. Introduction Learning Questions: 5 minutes

Use the questions below to learn people’s current knowledge, attitudes, and practices about keeping food and utensils clean.

Introduction Learning Questions: • We know that hands can be dirty and that water can be dirty. What about food? Can food be dirty? • Do you or anyone you know wash their food before eating? o What kind of food? o Why or why not? • Do you or anyone you know wash your plates? o Why or why not?

2. Dramas: 35 minutes

Divide the participants into five groups and give each group a poster G1 through 5 (you may need to explain to the fifth group what a drying rack is and does.) Give each group ten minutes to prepare a short (under 5 minutes) drama demonstrating how the behavior pictured prevents the spread of disease. After each group performs their drama, ask the relevant activity questions.

Activity Questions for Poster G1 - Washing Fruits and Vegetables: • Do you think washing our fruits and vegetables a good idea? • Why or why not? • What might make fruits and vegetables dirty?

Activity Questions for Poster G2 - Food Dish and Serving Spoon: • How can utensils be dirty? • How can utensils contaminate the food we eat? • Why is using a clean utensil to serve food important?

Activity Questions for Poster G3 -Washing Dishes: • How can we make sure our eating utensils and dishes are clean?

Activity Questions for Poster G4 - Covered Food: • How can flies contaminate the food we eat? • How can covering food keep us healthier?

Activity Questions for Poster G5 – Drying Rack: • What are different ways people in this community dry dishes? • Do people in your community use drying racks? • How does using a drying rack keep your utensils clean? (Remind participants what they learned in the SODIS lesson about the effect of the sun on germs. Also point out that the containers are face down, keeping out flies and dust.) • How can you increase the use of drying racks in your community?

51 mWASH Manual Community Health and WASH Lesson 2.11 Women’s Health

Lesson 2.11: Infant and Woman Health

Purpose of Lesson: • To learn how menstrual hygiene management and breastfeeding are connected with health and WASH Objectives: • To understand the importance of menstrual hygiene management • To review proper behavior for menstrual hygiene management • To discuss key aspects of breastfeeding for improved child health Materials: • Flipchart and markers Preparation: 1. Write the list of essential items for menstrual hygiene at homes and schools on a flipchart. 2. Write the four statistics used in section 4 on separate slips of paper

Time: 65 minutes

Background • Menstruation o Menstruation is a normal and natural process that is integral to human life. Most women and girls of reproductive age will menstruate every month for 2-7 days. However, in many countries around the world, it is a taboo topic and the practical aspects of menstrual hygiene are ignored. Often, those who are menstruating are stigmatized and excluded from regular social and cultural activities, and they do not have access to the WASH facilities and resources they need to manage menstruation hygienically and with dignity. o The negative impact is especially relevant for school-age children. Without adequate sanitation facilities at school, girls are embarrassed to attend school and many miss up to a week of school each month or drop out altogether when they begin menstruating. In addition to mental and emotional distress, poor menstrual hygiene can lead to infections and disease. o Practically, women need a washing station for sanitary materials as well as a safe way to dispose of used materials. These simple interventions help women and girls improve their hygiene and regain a sense of dignity related to menstruation. o Essential Items for Menstrual Hygiene at Homes and Schools: § Clean water and soap for washing hands, genitals, and used cloths/pads § Private place to change sanitary materials § Private and convenient place for disposing of used materials, or drying them if reusable § Access to affordable, environmentally friendly sanitary materials § Support from teachers, parents, friends, and spouses

52 mWASH Manual Community Health and WASH Lesson 2.11 Women’s Health

• Breastfeeding o Breastfeeding is one of the most important ways to promote child health, and it provides infants with health benefits that last into adulthood. It is especially important in countries where there is limited access to safe water and sanitation. Breastfeeding is related to child survival, and diarrheal disease in particular, through the following ways:16, 17 § Increases an infant’s immunity to infectious diseases and help’s an infant recover more quickly from illness § Improves an infant’s underlying nutritional status, which also makes it less likely to get sick and helps it recover more quickly § Provides much-needed hydration during an episode of illness; sometimes breastmilk is the only thing an infant will consume while sick § Provides a safe source of fluid for an infant, rather than unsafe water o Statistics that demonstrate the impact of breastfeeding on diarrheal disease and child health:18 § In 2013, proper breastfeeding could have saved the lives of more than 588,000 infants § Of the infant deaths due to diarrheal disease and acute respiratory infections, up to 55% of could be attributed to improper breastfeeding practices § Babies who are not breastfed for the first 6 months are 10.5 times more likely to die from diarrhea than babies who are exclusively breastfed § A baby 6-23 months who is not breastfed is 2.2 times as likely to die from diarrhea o If a mother is having trouble breastfeeding, she should discuss this with a health worker. Other women who have successfully breastfed their children can also provide support and encouragement. • Definitions: o Exclusive Breastfeeding: "Exclusive breastfeeding" is defined as no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines)19 o Complementary feeding: Complementary feeding is defined as the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The transition from exclusive breastfeeding to family foods – referred to as complementary feeding – typically covers the period from 6 - 24 months of age, even though breastfeeding may continue to two years of age and beyond. This is a critical period of growth during which nutrient deficiencies and illnesses contribute globally to higher rates of undernutrition among children under five years of age.20 o Menstruation: a discharging of blood, secretions, and tissue debris from the uterus that recurs in non-pregnant post-puberty females at approximately monthly intervals21

16 http://www.unicef.org/nutrition/index_24824.html 17 http://www.who.int/maternal_child_adolescent/topics/child/nutrition/breastfeeding/en/ 18 Laura M Lamberti et al., “Breastfeeding and the risk for diarrhea morbidity and mortality,” BMC Public Health Vol 11 Suppl 3 (2011): S15. Accessed June 16, 2015. doi: 10.1186/1471-2458-11-S3-S15. 19 http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/ 20 http://www.who.int/elena/titles/complementary_feeding/en/ 21 http://www.merriam-webster.com/dictionary/menstruation

53 mWASH Manual Community Health and WASH Lesson 2.11 Women’s Health

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • What different hygiene-related behaviors have we discussed so far? • Do you know any other types of hygiene?

Explain that this lesson will cover hygiene as it relates to infant and woman health. If someone asks about environmental hygiene, this will be covered in the next lesson.

Additional Introduction Learning Questions: • How do girls learn about menstruation and menstrual hygiene? • How do new mothers usually learn about breastfeeding?

2. Importance of Menstrual Hygiene Management: 15 minutes

Break participants into 4 groups and ask each to discuss one of the questions below. After a few minutes they will share their results. After groups share, fill in missing information from the background section.

Activity Questions: • What could be the negative effects of menstruation being a taboo topic in a community? • What could be the positive effects of menstruation being an acceptable, not taboo, topic in a community? • What could be the negative effects of missing or inadequate sanitation and menstrual hygiene facilities for girls in schools and homes? • What could be the positive effects of proper sanitation and menstrual hygiene facilities for girls in schools and homes?

3. Proper Menstrual Hygiene Management: 20 minutes

Participants will now consider the way menstrual hygiene should be properly managed. Post the flipchart list you prepared of essential items for menstrual hygiene both at home and at school. Ask participants to look at the list and to write them in a notebook. Have them underline any that they currently have in their home. Have them circle any they do not have in their home. Ask the participants to think of a way they could add any of the circled items to their homes.

Ask participants to look again at the list again and this time to think about a school in their community. Ask them to consider how many of the listed items are present for the girls at that school. Lead a discussion using the question below.

Discussion Question • Do you think there is anything parents could do to improve the health and dignity of girls during their menstruation periods? • Do you think there is anything the school administration or teachers could do to improve the health and dignity of girls during their menstruation periods?

Then ask participants to read through silently the following steps to menstrual hygiene management. They should circle the key words and phrases that they see. After a few minutes, ask participants to call out the words and phrases circled.

54 mWASH Manual Community Health and WASH Lesson 2.11 Women’s Health

1) Washing • Reusable menstruation cloths should be cleansed regularly in clean water with soap. Cloths should be hung to dry in a clean place that is in the sunlight but away from public view. If it can’t be dried in the sunlight, then it should be ironed before use. Cloths that are not washed and dried properly can lead to infections. • Women and girls should wash their genitals with soap and water every day during menstruation. They should also wash their hands after handling menstruation materials. • Latrines, at home and at schools, should have washing stations equipped with clean water, soap, and a place where reusable cloths can be hung to dry. Stations should be located close to school or home, and they must be private so women can avoid undesired attention and stigmatization. 2) Disposal • Latrines, at home and at schools, should be equipped with solid waste bins that are emptied often. Containers should have lids to limit flies. Contents should be burned or buried. • If the menstruation material is natural and biodegradable, it can be put directly into a pit latrine (but not a pour-flush). However, this can cause the latrine to fill up more quickly. 3) Education • Women and girls should be educated on the menstrual cycle and how to manage their menstruation hygienically. Men and boys should be taught that menstruation is normal and should have their negative perceptions challenged. They should be taught how to support their wives, sisters, and friends in their menstrual hygiene. Schoolteachers should be taught to create a supportive environment for girls at schools.

4. Keys to Proper Breastfeeding: 20 minutes

Explain that we will now talk about breastfeeding. Ask the group to explain how breastfeeding relates to child health and to diarrheal disease in particular. Fill in with information from the background section.

Have a volunteer read the first key to proper breastfeeding, below. This one is self-explanatory so does not need to be re-stated. Ask another volunteer to read the second key; then ask someone else to restate it in his or her own words. Do the same for the third and fourth keys.

Keys to proper breastfeeding

1) Early initiation of breastfeeding: Newborns should begin breastfeeding within one hour of birth.

2) Exclusive breastfeeding for first 6 months: Babies 0-6 months old should be exclusively breastfed, meaning they receive only breast milk (no water, other liquids, or solid food). Breast milk provides all of the nutrition and hydration a baby needs during the first 6 months of life. During the first few days after delivery, a mother produces a thick yellowish milk called colostrum that is very important for the baby and helps protect it from disease.

3) Continued breastfeeding until 2 years old: Babies 6-24 months old should continue receiving breast milk as well as complementary (solid) foods that are safe and age-appropriate.

4) Continued and even increased breastfeeding during illness of the child. When a child is sick with something like diarrhea, breastfeeding can improve their hydration and provide important nutrients to help in healing. In many cases, breast milk is the only thing a sick child will be willing to eat or drink.

55 mWASH Manual Community Health and WASH Lesson 2.12 Environmental Hygiene

Lesson 2.12: Environmental Hygiene

Purpose of Lesson: • To learn how environmental hygiene is connected with health Objectives: • To learn the benefits of using a rubbish pit • To realize the negative effect that open defecation has on the environment • To understand the reasons for keeping the area around the well free of rubbish Materials: • Poster Set H: Environmental Hygiene Preparation: 1. Gather all necessary Poster Sets. 2. If doing the drama activity, select four participants to act out a drama about disposing trash in a rubbish pit.

Time: 45 minutes

Background • Rubbish pits o Rubbish pits can be important because: § All rubbish is kept in one area and not spread around the compound. § Rubbish can be easily burned, buried, or collected if it is in one place. o A rubbish pit should be located a safe distance away from any water sources or food preparation areas. Waste that cannot be recycled for other uses should be put in the pit. These items include tins, glasses, plastic bags, and other containers. Once the pit fills up, it should be covered with dirt and a new pit should be dug. • Environment around a water source o Animals can cause damage to a water source itself o When animals defecate, more germs are close to the water source o Feces and trash near a water source increase the number of flies and the likelihood of water becoming contaminated (if flies land on the tap or on water that is sitting after being collected) o Without a soak pit or garden at the end of a hand pump, water may become stagnant and increase the number of mosquitoes and spread malaria • Human feces always contain large amounts of germs, some of which may cause diarrhea. When people defecate in the open, flies will feed on the feces and can carry the germs on their bodies and feet. Not only can this spread diarrhea to other people, the feces will most likely remain on the ground and infect more people over time. Open defecation also creates bad odors, an increase in flies, and makes the surrounding environment less pleasant. • Animal pens keep animals safe without letting them inside the home. Animals can spread disease through their own feces and by stepping in the feces of other humans and animals. They also increase the number of flies, which spread disease. • Reasons clean compounds are good: o Less chance for disease to spread. o Less flies around the compound. o People can be proud of their area or community. o Less chance of getting hurt on trash or other items lying around.

56 mWASH Manual Community Health and WASH Lesson 2.12 Environmental Hygiene

1. Introduction Learning Questions: 5 minutes

Introduction Learning Questions: • Would you say the environment in your community is clean, dirty, or in between? Why? • What are the cleanest areas of your community? • What are the dirtiest areas of your community?

Divide the participants into 4 groups and handout one Poster from H3-H6 to each group. Ask them to be prepared to present the following to the rest of the participants - Describe what is shown in your poster - Explain how your poster relates to environmental hygiene

2. Rubbish Pits: 10 minutes

Ask the group with Poster H3 to present their poster first. Then ask the learning questions below. Fill in missing information from the Background section.

Introduction Learning Question: • Does anyone in your community use a rubbish pit to dispose of rubbish? • How would rubbish pits help stop the spread of disease? • How can having a rubbish pit improve your household’s or community’s cleanliness? • Where do you think a rubbish pit should and should not be located?

3. Keeping the Area Around the Well Clean: 10 minutes

Ask the group with Poster H4 to present. Then ask the learning questions below. Fill in missing information from the Background section.

Discussion Questions: • Why is it important to keep the area around a well clean and fenced? • What kind of impact might animals have on the clean water that comes from the well? • Why might you not want to have rubbish around the well? • How can you keep the area near a water source clean?

4. How Open Defecation Hurts the Environment: 10 minutes

Ask the group with Poster H5 and then H6 to present. Then ask the learning questions below. Fill in missing information from the Background section.

• What negative effects of feces have we discussed so far? • How might animal and human feces affect the environment? • What do you normally do with the children or animal feces around your compound? • What should you do with the children or animal feces around your compound?

57 mWASH Manual Community Health and WASH Lesson 2.12 Environmental Hygiene

5. Compound Comparison: 5 minutes

Show participants Posters H1 and H2. Pass the posters around so everyone can see them clearly. Lead a discussion using the following questions. Fill in this discussion with information from the Background section.

Discussion Questions: • What are the differences you see between these two pictures? • What things does the clean compound have that the dirty compound does not have? • Why is it important to have a clean compound? • Which picture looks more similar to your compound?

58 mWASH Manual Community Health and WASH Lesson 2.12 Environmental Hygiene

Section 3. Framework for Change: Introduction

In the previous sections, we discussed how God is restoring relationships that were broken by sin. These relationships between humans and God, humans and other humans, and humans and the environment are now being restored through the Holy Spirit. We have the opportunity to be part of that restoration by practicing holism, capacity building, multiplication, and inclusion. We have now learned the most important health behaviors which families and communities need to practice in order to have healthy lives. This knowledge of making water safe, washing hands, and using latrines has the potential to save many lives.

However, we are still missing some key information. Increasing a person’s knowledge does not always lead to behavior change22. In this section, we will learn what makes people change their behavior, and how we can work in such a way that causes lasting behavior change. Every community in every nation is different - each has its own unique resources and challenges. Therefore, our programs need to provide a solution that appropriate for the specific communities in which we are working which addresses the challenges that they face and the resources they already have. We will now learn how to create an appropriate and effective WASH solution and how to promote that WASH solution in a way that brings about deep and lasting change.

22 http://www.coregroup.org/storage/documents/Workingpapers/dbc_curriculum_final_2008.pdf.

59 mWASH Manual Framework for Change Lesson 3.1 Behavior Change

Lesson 3.1: Behavior Change

Purpose of Lessons: • To understand the factors that influence behavior change Objectives: • To learn the Behavior Change Formula • To consider specific barriers to transformation impacting sanitation improvement in local communities Materials: • Flipchart and markers • 3 large stones • 1 large cooking pot • Optional: small stones, bottle caps, or other object of similar size –2 per participant Preparation: 1. Optional Voting Activity: Write on separate pieces of paper or strips of flipchart paper: “Dissatisfaction with how things are”, “Vision of how things could be”, “Knowledge of first steps”, and “Barriers to change” 2. Label 3 stones “Dissatisfaction”, “Vision”, and “First Steps”, and the pot “Behavior Change”. Think of a time you tried to change a behavior and it was difficult. 3. Review Background material carefully

Time: 40 minutes

60 mWASH Manual Framework for Change Lesson 3.1 Behavior Change

Background • Behavior Change Formula, adapted from Dannemiller23 o C = D x V x F > B § Change occurs when Dissatisfaction (with how things are) multiplied times Vision (of how things could be) multiplied times First steps (ie: people’s knowledge of and ability to make immediate steps toward the future vision) are greater than Barriers to change o To make change more likely, one must increase dissatisfaction with the current status, clarify an appealing vision of what is possible, create tangible and believable first steps, and decrease barriers (real or perceived). o If Dissatisfaction, Vision, or First Steps are not present then change will not occur. All together, one or two may be weak but if the third is stronger than the barriers then change can still occur. o Example 1: In the River Crossing Drama from Lesson 1.1 change took place - people crossed to the other side a river. They had high dissatisfaction with being on their side - they really wanted to go to the other side. They had high vision of how things could be – they could see the other side and could image that it could somehow be possible for them to be on that side. Their knowledge of first steps was missing – they had no idea how to cross the river. The barrier was high – the river was strong and wide. First, a person came and carried Friend 1 across. The barrier did not change but Friend 1 overcame the barrier because the helper carried him/her through the first steps. The helper then showed Friend 2 how to take the first steps on his/her own. This enabled Friend 2 to teach first steps to Friend 1 and they were both able to achieve change. o Example 2: To create the change in which a household constructs a latrine, a development worker may increase dissatisfaction by showing them how their current practice (open defecation perhaps) is spreading diseases. The vision of how things could be is clarified by discussing with them what type of latrine they would most enjoy and what they would do with their time or money if they were healthier more often. The tangible and believable first steps could be created by discussing a plan with the household of first digging a pit with basic privacy and logs to stand on which are at least safe, then by adding over time an improved slab, stronger walls, a roof, and a door. In order to reduce barriers, the development worker can ask the family what will be most difficult in achieving that plan and help them consider locally-available resources which would be effective or helping find community members willing to help someone dig a pit who may be unable to do so themselves.

23Dannemiller, K. D., & Jacobs, R. W. (1992). Changing the way organizations change: A revolution of common sense. The Journal Of Applied Behavioral Science, 28(4), 480-498. http://www.dannemillertyson.com/library/Accelerating%20Strategic%20Change%20Article%20pdf.pd f

61 mWASH Manual Framework for Change Lesson 3.1 Behavior Change

1. Introduction Learning Questions: 5 minutes

Ask participants to consider a time they tried to change a behavior and found it difficult. Share this time with a neighbor. Use the discussion questions below to learn participants’ current efforts to change behaviors.

Introduction Learning Questions: • In your work with communities, do you ever try to get people to change their behavior in any way? o If so, have you found it difficult or easy to change people’s behaviors? o How do different people respond? o What are different ways that you try to lead them to change their behavior? • Do people ever change their behavior then go back to their original behavior? If so, why?

2. Change Formula: 5 minutes

Explain that sometimes people find behavior change difficult, but there are things we can do to help make behavior change more likely and longer lasting. After you ask each question below, write the words “dissatisfaction”, “vision”, and “first steps”, and “barriers”, respectively, on a flipchart.

• [Dissatisfaction] What does the word “dissatisfaction” mean to you? What other words are similar? • [Vision] What word do you use to describe people’s goals, vision, or dreams about their future? • [First steps] Have you heard of the saying “The journey of a thousand miles begins with a single step”24? What do you think that means? • [Barriers] What is a barrier? What does a barrier do?

Introduce the concept of the behavior change formula using information from the first three points of the Background section. Write the formula and explain what each letter represents.

3. Optional: 3 Stone Activity: 10 minutes

To re-emphasize the importance of all three components and how they work together, present the three stones labeled “Vision”, “Dissatisfaction”, and “First Steps”. Place them in a cluster and then place the “Behavior Change” pot balancing on top of them, while explaining that when all three elements are present, behavior change occurs. After pausing to ensure people understood that concept, explain that if anyone of the three are missing, then behavior change will not occur. While saying this, pull one of the stones away so the pot falls over. Make sure to ask for questions before moving on.

24 Quote attributed to Lao Tzu

62 mWASH Manual Framework for Change Lesson 3.1 Behavior Change

After this activity, ask participants to remember their behavior change example from the beginning of the lesson. Consider which of the three factors was missing or was low. Ask a few participants to share.

Then, use the community example in the background, or make up a different, appropriate example, to demonstrate how the formula applies to a specific situation.

4. Optional Activity: Voting on Threats to Change: 15 minutes

Lay the labels “Dissatisfaction” “Vision” “First Steps” and “Barriers” across the ground, with “Barriers” a little further separated than the others. Explain that in our work, the change we are working to achieve is the end of the global water and sanitation crisis. Give each participant two rocks and ask them to consider the two biggest threats to this change in the rural villages in the region. When they are ready, have participants vote on the one or two biggest threats (they can use both rocks on one threat if they think it is most significant, or divided between two different threats) and explain their reasoning.

Activity Question (participants answer as they vote): • Do you think the biggest threat to the change we hope to see is low dissatisfaction with how things are now, low vision of how things could be, low understanding of first steps, or high barriers?

Post-voting Activity Question: • If you are working in a community to change their behavior and change is not occurring, how can this formula help you consider why there is no change?

63 mWASH Manual Framework for Change Lesson 3.2 Intro to Community Triggering/ Total Sustained Change Lesson 3.2: Community-Led Total Sanitation

Purpose of Lesson: • To discuss and practice Community-Led Total Sanitation triggering Materials: • Transect Walk: o None • Community Mapping: o Tools to draw or outline map (ex: sticks, thread) o Cards or other items to mark households o Yellow powder or some noticeable mark to show open defecation areas • Shit Calculation: o Flipchart and markers o Blank cards • Feces Flow Diagram: o Flipchart and markers o Blank cards o Glass of water o Strand of hair or blade of grass o Feces or something that represents feces

Preparation: 1. Be familiar with the different activities of Triggering. It may be helpful for facilitators to each be prepared to help 1 of the 4 groups. (See Appendix 6-9) 2. Divide participants into 4 groups based on gender, personality, leadership, and experience with CLTS. 3. Decide how to allow participants to prepare for their presentations: • 15-30 minutes for preparation, 30 minutes for presentation and discussion. • Participants can be given time during class to prepare for to present their activities. • Alternatively, preparation can be given as homework the night before presenting. Time: 3 hours

Background • The goal of Community-Led Total Sanitation (CLTS) is to create immediate, community-wide awareness of the problem of open defecation, and desire to change. CLTS focuses on the community as a whole and tends to bring about change at the community-level. o Immediate: because the problem is urgent and people are dying o Community-wide: because change will spread much quicker and will be more likely to occur if everyone in a community is committed to the same goal o Awareness of the problem of open defecation: because in order for change to occur, people must truly understand how great of a problem open defecation is and that people are dying because of it o Desire to change: because high dissatisfaction with open defecation is a strong motivation to change. • Central ideas: o CLTS focuses on a community’s attitude toward their own practices. CLTS stimulates a collective sense of disgust, shame, and fear among community members as they confront the crude facts about mass open defecation and its negative impacts on the entire

64 mWASH Manual Framework for Change Lesson 3.2 Intro to Community Triggering/ Total Sustained Change community. The basic assumption is that no human being can stay unmoved once they have learned that they are ingesting other people’s feces. o Through a series of activities, communities come to these realizations without being told by the facilitator. This makes the process more powerful. o The four activates involved in CLTS take place in a ½-1 day event, led by a facilitator, and with as much of the community present as possible. o An important aspect of CLTS is not to prescribe the best and most durable model of latrine to the community at first, but to initiate local action for communities to look for their own alternatives to open defecation. It aims at stopping open defecation by the entire community. • Context of CLTS: o CLTS is useful when a certain part of the community wants to put pressure on the other part who are practicing poor or partial sanitation and hygiene so that change exist at wider community level. o CLTS works better in densely populated, rural, sedentary communities than scattered pastoralists due to benefits of peer pressure, availability of land, and prolonged ability to use sanitation facilities. o One criticism raised about CLTS is that it fades out before permanent change is achieved in sanitation and hygiene behavior in communities. § One study showed average slippage rates (returning to practice of open defecation) of 21% over time25 • Crudest word for “feces” o During CLTS it is important to determine a word for feces that evokes feelings of disgust and repulsion. This should be done through thoughtful discussion with the community, and should not be done right away. o “A poor facilitator may insensitively start using [the crudest word] liberally without first seeking the endorsement of the community. This may elicit negative reaction from the community and may result in bad shame. A good facilitator on the other hand will conduct the process in a way that enables the community on its own to mention the crude name for shit in the local language. Of course most the time the rural community rarely mentions this crude word quickly. Therefore a good facilitator must embody the virtue of patience. Through patience and further probing a community eventually mentions the word ‘shit’ in the local language. When the crude name of ‘shit’ is imposed in a community meeting without going through a participatory process that ‘legitimizes’ it and gives it collective ownership in a meeting, it amounts to humiliating the community. As such a community may feel resentful that an outsider is imposing on them something that is contrary to their values.”26 o “We have also realized that consistent use of the most unpleasant words for shit have created an enabling environment for accepting CLTS as a preferred approach in organizations, and a recipe for changing sanitation behavior in communities.”27 • Village CLTS triggering refers to the process of mobilizing villagers using a set of participatory tools to analyze their hygiene and sanitation situation and agree on collective action for change. • Triggering should occurring during a single day, and should take 3-4 hours.

25http://www.communityledtotalsanitation.org/sites/communityledtotalsanitation.org/files/Plan_International_ODF_Sustai nability_Study.pdf 26 Oteino, Philip. The Shame Question in CLTS. IDS. April 2012. 27 Zombo, Mariama Munia. Participatory Learning and Action. Tales of Shit: Community Led Total Sanitation in Africa. IIED. 2010. 73.

65 mWASH Manual Framework for Change Lesson 3.2 Intro to Community Triggering/ Total Sustained Change

• Triggering Activities: o Purpose: To analyze where the community is on the sanitation ladder and provide opportunity for ignition.

§ Defecation area transect walk § Sanitation mapping § Shit calculation § Feces flow diagram • An alternative to CLTS can be found in Appendices 10 and 11

66 mWASH Manual Framework for Change Lesson 3.2 Intro to Community Triggering/ Total Sustained Change 1. Quick Review: 5 minutes

Ask the participants if they have ever experienced Community-Led Total Sanitation, and have them share their experiences. If no one has experienced CLTS, ask them what they think it means, then give an overview of CLTS using the information in the Background section. Have the class discuss the following questions.

Discussion Questions: • What are some things you need to do before the day of triggering? • What is the purpose of using a crude word to talk about feces? o What might be the challenges?

Be sure to emphasize the following advantages to CLTS. • Immediate change • Involves the entire community • Has great potential for growth to other communities

Be sure to emphasize the following disadvantages of CLTS. • Uses the concept of shame • Causes immediate change but often this change is not permanent • Promotes lowest level of sanitation above open defecation rather than moving up the sanitation ladder

2. Triggering Activities: 3 hours

Explain that we will now learn and practice the day of Triggering, which the participants will lead in communities. Although different groups will be doing different activities right now, all four activities will probably be led by 1-2 facilitators in a community. Divide the class into 4 groups. If possible, each group should have someone who has experienced CLTS. Each group should be paired with 1 of the first 4 Triggering activities.

Guide groups to their corresponding Triggering activities, found in Appendix 6-9. Each group will have thirty minutes to prepare their activity. When finished, groups present their activity to the class. Each group’s activity should take 15-30 minutes.

The class will play the role of the community so that everyone participates. The group facilitating the activity may choose to have 1 or 2 facilitators and the rest pretend to be community members who will help lead the community’s response and reaction to the community and engage the rest of the participants as community members. It is important that everyone participate in each activity as either a community member or facilitator so that everyone is very familiar with the process.

After all activities are completed, ask the following questions:

Activity Questions: o In what ways does CLTS increase people’s dissatisfaction with open defecation? o In what ways does CLTS help people achieve the first steps toward better health?

67 mWASH Manual Framework for Change Lesson 3.5: Community Triggering – Ignition Moment

Lesson 3.5: CLTS - Ignition Moment

Purpose of Lesson: • To learn how to handle different community reactions to triggering and maintain community leading of the process Materials: • Flipchart or chalkboard • Markers or chalk • Scissors Preparation: 1. Be familiar with different types of Ignition Moments 2. Create a label with the name and definition of each Ignition Moment 3. Hang the labels around the room Time: 50 minutes

Background • Ignition moments: • Be very alert for the Ignition Moment. It is the moment of collective realization that due to open defecation all are ingesting each other’s feces and that this will continue as long as open defecation goes on. When this happens there is no need to continue with other activities. • Often at this stage the spirit goes high and arguments begin as to how to stop open defecation. • In general triggering produces different responses. The common patterns of responses and corresponding actions include: o Bright Fire: Where the entire community is fully ignited and all are prepared to start local action immediately to stop open defecation. o Small But Hopeful Fire: Where a majority has agreed but a good number are still not decided. o Scattered sparks: Where the majority of the people are not decided on collective action, and there are many people undecided, and only a few have started thinking about going ahead. o Wet Match: Where the entire community is not at all interested to do anything to stop open defecation. • How a facilitator should act during an ignition moment: • Don’t interrupt or advise. Quietly listen to the discussion. • If questions are thrown to you, tell them that, as an outsider, you have little local knowledge and that they know much better than you what is best to do in their local situation. • Tell them that they are free to choose anything including continuation of open defecation. • Tell them not to misunderstand you as a promoter of latrines suggesting to stop open defecation. Tell them to feel free to continue their old practice of Open Defecation (OD) if they wish. • DO NOT worry if no one talks about starting any local action then and there. In that case thank them again and tell them that you will record them as a village where people are willing to continue open defecation and eating one another’s shit. Do not feel that you have somehow failed. You have probably started a process. • If/when latrine costs are discussed: o At that point some might say they do not want to continue. Ask why? The usual reply is that latrines are too costly to build. Ask what a normal latrine should cost, and what

68 mWASH Manual Framework for Change Lesson 3.5: Community Triggering – Ignition Moment

would be the minimum cost. Common answers are $100 – $250 or more. Tell them about low cost latrines constructed elsewhere, and that 1 can be constructed for only $3-$4. Most will not believe this. (Ask them to raise their hands if they are really unsure). o If they do so, explain with detail on chart paper on a wall. Quickly draw a simple pit latrine. (Do not take a drawing with you, but draw it on the spot.) Ask how much that would cost and how difficult it would be to construct a similar direct pit latrine? Let them know that this was not your design, but one developed by poor people in one of the poorest countries of the world. You could also share experiences of other communities who have taken up total sanitation and have achieved success. o Ask them the cost. They may say even less than you said, and that they will go ahead and do it. Ask them to raise their hands, and then record their names on a sheet. o DO NOT prescribe models of latrines. Remember that the central idea of CLTS is not to prescribe the best and most durable model of latrine to the community at first, but to initiate local action for communities to look for their own alternatives to open defecation. • Your next action depends on what response you find at the end of ignition moment. Here is how a facilitator should act during each type of ignition moment: o Bright fire: Facilitate action plan (below). o Small but hopeful fire: Facilitate action plan (below). o Scattered sparks: Thank them for the detailed analysis and tell them not to misunderstand you as a promoter or salesperson of latrines or toilets. For now you should not continue to work in this village, but can consider returning some time in the future. o Wet match: Thank them all and leave. Do not pressure. For now you should not continue to work in this village, but can consider returning some time in the future. • Facilitating the Community’s Plan of Action (same day as Triggering) • The process of planning should concentrate on immediate positive action plans. • Questions to ask during Action Planning: § Who will promise to take immediate action? What action will you take? § When will you declare open defecation free village? § Who will you share this information we discussed today with to keep you accountable and for people not present today? § Who will follow up and ensure that every one achieves Open Defecation Free status by the agreed schedule? • Ask volunteers to write action plan, names of the people following up and timeline on a flip chart • Decide with the community an agreed date for a follow-up visit when you will declare ODF if they have achieved it, and will present them with an award. • More actions will come later during after ODF is declared.

69 mWASH Manual Framework for Change Lesson 3.5: Community Triggering – Ignition Moment

1. Introduce Ignition Moment: 10 minutes

Briefly explain what the Ignition Moment is using the first 2 points in the Background section from this lesson. This takes place during or at the end of the triggering activates.

Discussion Questions: • How do you think the facilitators should act during the Ignition Moment?

2. Explore Types of Ignition Moments: 30 minutes

Ask the participants to walk around the room and read the different Ignition Moments posted then to return to their seats when they have read each Ignition Moment.

Divide participants into 4 groups. Assign each group an Ignition Moment to act out and to demonstrate how a facilitator should respond in that situation. To prepare, groups should read carefully the instructions how a facilitator should act in general as well as during their type of ignition moment. Give groups 10 minutes to prepare. Dramas should be no more than 5 minutes long. Start with the Wet Match scenario and end with Bright Fire.

Activity Questions: • What did you see in this drama? • What did the facilitator do? • Would the group that performed like to add anything?

Remind participants that if a community has no desire to change their practice, it is recommended that the facilitator leave that community and move on to a different one. In the future, a follow-up can be conducted to see if the community’s desire to change is higher.

70 mWASH Manual Framework for Change Lesson 3.6 Community Triggering – Post-Triggering Stage

Lesson 3.6: CLTS - Post-Triggering Stage

Purpose of Lesson: • To learn how to transition from Community Triggering promotion to Total Sustained Change Objectives: • Discuss what can occur during the Post-Triggering stage • Learn what it looks like to incorporate key actors for sustained change Materials: • Flip chart or chalkboard • Markers or chalk Preparation: 1. Read the Background section. 2. Be familiar with the Post-Triggering stage of CLTS. Time: 30 minutes

Background • Post-Triggering involves encouraging the progression of communities towards becoming Open Defecation Free (ODF) This is enacted through follow up meetings, and recognition and verification. • The Post-Triggering stage will look different for each community. What happens depends on their response to Triggering and their willingness to carry out their action plan. • The post-triggering phase is very important. Community dynamics can change rapidly and go in different directions. Sensitive external encouragement and support can be crucial. • Facilitators and others in a support role need to be alert to what is happening. Timely interventions can make a big difference. • Triggering that is part of a training workshop has occurred without follow-up, and nothing has resulted. Triggering without follow-up is bad practice and should be avoided through forward planning and involving and linking with an organization and/or individuals who can and will follow up. • Building on action taken during the first day, facilitate and encourage: • The formation and activities of the sanitation action committee • Using the map of households to show sanitation status and progress • Developing individual family plans to stop open defecation. In the early days, related households often construct common latrines to share • Digging pits and using them as makeshift latrines for the short term • Getting commitments from better-off families to start constructing latrines immediately • Looking for suppliers of latrine construction materials • Interested members of the ODF communities could also be taken to other villages where such local initiatives on sanitary material fabrication started • Encourage better-off households to help the less well off to find a way to stop OD as they will also benefit • It is important to identify natural leaders and encourage them to take charge of ensuring that action plans are followed through and changes in behavior are sustained. • During Post-Triggering it is important to continue to involve key actors in the community. • Encourage help for the weaker and poorer members of the community • Encourage participation from those marginalized, usually women and children. Praise their efforts. • Purpose of Post-Triggering: Community action planning and follow up • Post triggering Tasks: o Monitoring community actions and ODF status o Verification o Fostering change o Extending to next step in the sanitation ladder without interruption

71 mWASH Manual Framework for Change Lesson 3.6 Community Triggering – Post-Triggering Stage

1. Group Brainstorm: 20 minutes

Using the Background section, briefly introduce the Post-Triggering stage. You may ask people familiar with CLTS to share their experiences with Post-Triggering.

Post the list of activities from the Pre-Triggering Lesson.

Activity Question: • Which of these activities or tasks need to be followed up on?

Circle or mark the activities noted on the list. With the class, go through each circled activity and ask the following question:

Activity Questions: • How can we follow up on this? • What steps would it involve?

After going through each circled activity. Add information from the Background section as needed.

2. Attitudes During Follow Up: 5 minutes

Discussion Questions: • How can our actions reflect Jesus even as we facilitate CLTS? • How should we respond if things are not going the way we think they should?

3. Application Discussion Questions: 5 minutes

Use the application discussion questions below to guide a discussion on how CLTS will change people’s behaviors.

Discussion Questions: • How will CLTS impact communities’ knowledge about WASH? • How will CLTS impact people’s attitudes toward WASH? • How does CLTS impact people’s WASH practices?

72 mWASH Manual Framework for Change Lesson 3.7 Total Sustained Change

Lesson 3.7: Total Sustained Change

Purpose of Lesson: • To learn how to work with key actors in communities to bring about Total Sustained Change Objectives: • To define the possible key actors for a promotion strategy Materials: • Flipchart or large piece of paper • Paper • Markers • Normal sized sheets of paper, and half sheets of paper Preparation: 1. Cut many half sheets of paper and strips of paper. Time: 60 minutes

Background • Total Sustained Change is achieved through training of key actors. Key actors are groups of people with influence in the community who commit to modeling good WASH practices and teaching others about WASH. • Key actors are people with any kind of influence, whether political, social, religious, or other. They can be men or women, young or old, rich or poor. Lifewater focuses on the following key actors: § Local government § Local schools § Local faith groups § Water committees § Influential households • There are 2 types of key actors – ones who drive community transformation and ones who have the potential to block community transformation. An example of key actors with potential to block transformation might be the local government may be key actors because they need to be included in the program t ensure that they support the program and won’t hinder it’s work. They are like gateways that the program must pass through to move forward, and so they are important key actors even though they may not actually drive the program forward. • Total Sustained Change gives roots to the behavior changes to prevent backsliding and it to keep communities moving forward with better WASH behaviors. Review the Background section of Lesson 3.2 Intro to Community Triggering and Total Sustained Change for more information.

73 mWASH Manual Framework for Change Lesson 3.7 Total Sustained Change

1. Review of Community Triggering and Total Sustained Change: 10 minutes

Now that we have finished learning about CLTS, review again the goal of Community Triggering and the goal of Total Sustained Change using the Background section of Lesson 3.2. Explain that we have now finished learning about Community Triggering and will begin learning about Total Sustained Change.

Remind participants that the main purpose of Community Triggering is to create immediate, community-wide awareness of the problem and desire to change. Also remind them that the main purpose of Total Sustained Change is to create a lasting commitment to change among individuals, families, and peer groups.

2. Brainstorming Key Actors: 35 minutes

1. Introduce the term “Key Actors” to the participants and describe some of the characteristics of key actors.

Definition of Key Actors: The key actors are specific groups of people that have influence in the community

Some characteristics of key actors are that they: b) Have influence on others. c) Are interested in leading transformation in the community OR have potential to stop community transformation d) Could be any age, gender, income-level, religion, etc.

2. Instruct participants to think of all the key actors that exist in local communities. As participants list different key actors, have 1 participant write each idea on separate pieces of paper. Then, arrange these pieces of paper on the floor in front of the participants. Encourage participants to continue thinking of all the possible key actors that are in a community, and if they do not list any of the categories included in the Background section, ask who, if anyone, are the key actors in the community within that category. 3. After the participants have finished suggesting key actors, ask participants to separate into a separate pile any key actors who they are not currently targeting in their work. 4. Using the pile of Key Actors who the participants are currently working with, arrange each Key Actor in a circle. If participants are all working with 1 organization, you may choose to write the organization’s name on a piece of paper and place in in the middle of the circle. 5. Then ask people to suggest ways that they can teach each group of key actors the wash lessons learned in WASH 101. Have a volunteer write each of these ideas (methods of teach the WASH lessons) on a separate strip of paper and place it next to the Key Actor on the floor. If the organization’s name is in the middle, you can lay the strips in between the organization’s name and the Key Actor’s name to show the connection.

74 mWASH Manual Framework for Change Lesson 3.7 Total Sustained Change

6. Discuss each key actor involved in the program and the best ways to teach each group of key actors the WASH 101 lessons. 7. If time remains, discuss or write down on more papers who all these Key Actors influence to show how great an impact can be had by working through Key Actors rather than if participants try to reach everyone in the community individually.

Activity Questions: • Are we ignoring any key actors that would help promote WASH in communities? o If so, move them to a third pile of “Possible Key Actors” which will be discussed in Section 4 • Are we ignoring any key actors that could block WASH transformation in communities? o If so, move them to a third pile of “Possible Key Actors” which will be discussed in Section 4 • How will these different key actors teach the WASH 101 lessons to the people around them on whom they have influence?

3. Connecting Key Actors to Community Triggering Monitoring: 5 minutes

Post the flipchart with the different activities and follow-up needed from Community Triggering. Ask participants to write the names of all the key actors who can support follow- up for each activity that needs to be monitored.

Discussion Question: • Why is it beneficial to include key actors in monitoring the progress of Community Triggering?

4. Understanding the power of key actors: 10 minutes

Explain that when key actors help us teach WASH in the communities to others and model it themselves, this makes the change that Community Triggering has started become sustained change that will last long into the future.

Discussion Questions: • In what ways can key actors influence their fellow community members differently than an outside person or a development worker? • Are we helping the key actors continue to grow and learn? o If so, how? o If not, how might we do so? Why might that be beneficial? • Are the key actors supporting, encouraging, and learning from one another? o If so, how? o If not, how might we do so? Why might that be beneficial? • Do key actors focus on changing Knowledge, Attitude, or Practices? o How so?

75 mWASH Manual Framework for Change Lesson 3.8 Adapting Communication Methods

Lesson 3.8: Adapting Communication Methods

Purpose of Lesson: • To learn different ways to effectively communicate a message to different groups of people Objectives: • To learn how to best communicate in different regions • To think of communication methods that may be effective for different key actors Materials: • Flipchart or large piece of paper • Markers • Sheets of paper Preparation: 1. Prepare for the telephone game by reading the instructions and breaking participants up into 3 groups. Also, gather 3 flipcharts and choose 3 shapes that participants will trace. Time: 55 minutes

Background • Telephone game instructions: Have 3 groups of participants stand single file in a line facing the front of the classroom; each person’s back should be facing the person behind them. Hang flipchart paper in front of each group. With the end of a marker (not your finger), trace a simple shape on the back of the last person in line. That person will then take the marker from you and do the same to the person in front of him or her. This continues until it reaches the front. The first person then draws the shape on the piece of flipchart paper. Have groups do this as fast as they can. The winner could be the group that draws the shape closest to the original shape. • When our way of communicating is not clear, the message we want to pass along may not be heard correctly or understood.

76 mWASH Manual Framework for Change Lesson 3.8 Adapting Communication Methods

1. The Telephone Game: 20 minutes

Use the instructions for the “Telephone Game” in the Background section to prepare for the lesson. Split the class into 3 groups and instruct each group to stand in a line facing the front of the room. Place a piece of flipchart paper in front of each line.

Start the game by reading the game instructions to the participants and using a marker (with the cap on) to trace a different shape on the back of the first person in each line. Say, “start” to start the game. Participants should trace the same shape on the person in front of them. This continues until it reaches the first person in line. This person then uses the marker to draw the shape on the flipchart paper.

After this is done, name the winning team by drawing the correct shape next to the shape the teams drew. Whichever team was closest to the original shape, wins. Have participants return to their seats and start a discussion using the following questions.

Activity Question: • What happened to the shape as it was passed from person to person? • Why do you think this happened? • How does this same thing happen when you are communicating? • How can you stop this from happening?

2. Different Ways to Communicate: 10 minutes

Using the facilitation questions below, ask participants to think of different ways a message can be communicated. Ask for a volunteer to list the communication methods mentioned by the group on a piece of flipchart paper.

Discussion Questions: • What are some common ways that groups promote themselves, their products, or their beliefs in the communities in which you work? (If participants are having trouble answering, give a few examples such as radio, television, speaking at large events, and posters.) • Would you say this kind of promotion is successful in the communities? • Why do you think they are or are not successful? • What are some ways of communicating a message that we discussed in the previous lesson?

3. Communication with Key Actors: 25 minutes

Assign each group a different Key Actor that was discussed in the previous lesson. Have each group discuss what the best method(s) of communicating WASH to that group of Key Actors would be and the advantages and challenges of using the communication method(s) they chose. After discussions have ended, instruct participants to return to the group and tell what their way of communication was and share their ideas with the group.

77 mWASH Manual Framework for Change Lesson 3.9 Adapting Learning Tools

Lesson 3.9: Adapting Learning Tools

Purpose of Lesson: • To learn tools for finding out information about a community which will help make a WASH program more effective Objectives: • To review how baselines are important in programs • To learn how to facilitate focus groups • To learn how to use pocket charts to gain information about communities Materials: • A pocket chart • 1 small rock or bottle cap for each participant present • Pocket Chart pictures Preparation: 1. Become familiar with the Focus Group Discussion role play. 2. 6 people are needed to participate in the focus group discussion: a. Be sure to tell the participants that this is a role play, they do not necessarily need to act as if they are answering the questions as themselves. b. Focus group moderator (should be class facilitator unless a participant is identified with experience in facilitating Focus Groups) c. Recorder (facilitator) d. Community Participants (4 volunteers)- you might have all men, all women, or another group with similar backgrounds 3. Set up 6 chairs in a half circle for the focus group role-play.

Time: 65 minutes

Background • A pocket chart is a tool for gathering information; pocket charts offer a private way to answer difficult or embarrassing questions. • A focus group discussion is a discussion with a small group of people. A facilitator will gather a group of 6 to 12 people, ask them questions and listen to their responses. See more detail about Focus Group discussions in Appendix 12. • Focus group discussions are a great way to hear about a subject from the people in the group. They especially help to find out what people really think and why they may think that way. • The main point of conducting a focus group discussion is to listen to what people have to say. You may not agree with everything they say; however if the promotion is to be focused on them, you will need to listen to what they think about latrines, handwashing, or other subjects. • Qualities a facilitator should have: o Not judgmental o Uses open questions o Culturally-appropriate o Respectful o Patient o Pays attention to participants

78 mWASH Manual Framework for Change Lesson 3.9 Adapting Learning Tools

1. Introduction Learning Questions: 5 minutes

Use the questions below to learn about the participants’ experience with community learning.

Introduction Learning Questions: • What do we need to know about a community before we begin a WASH project? • If I or someone else from outside the community were to go into a community you work in, would I immediately know all this information about what communities’ knowledge, attitudes, and practices? o If so, how would I know these things? o If not, how could I find out these things? • Do you already know everything about the communities’ current knowledge, attitudes, and practices? o If so, how did you learn this? (If not mentioned, be sure to ask if the baseline survey gave them any information about the communities’ current knowledge of WASH). o Could there be anything that you still need to learn?

2. Household Survey: 10 minutes

Explain that 1 method of learning about a community is through a baseline Survey. Use the discussion questions below to guide the discussion.

Discussion Questions: • What did you learn when you conducted the household study? • Why is it important to do a household survey before working in a community? • What type of information is easy to find out using a household survey?

3. Focus Groups: 20 minutes

Introduction Learning Question • What experience do you have with focus group discussions?

Explain to the class that they will watch an example of what a focus group may look like in a community, then have the selected participants perform the drama.

Activity Questions: • What did you observe? • What steps are involved in conducting a focus group?

Based on the participants’ knowledge of focus groups, fill in any needed information from the Background section.

Discussion Questions • What is the difference between someone who teaches something and someone who facilitates a discussion? • What qualities should a facilitator have?

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• Ultimately, what is the role of the facilitator? [listener, helper, guides conversation, encourager, etc.] • What do we learn by conducting focus groups that may be difficult to find out in a household survey? • What did you learn about what this group’s knowledge? • What did you learn about the group’s attitudes? • What did you learn about the practices of the group?

4. Lesson: Pocket Chart: 30 minutes

Hang the pocket chart where all can see it. Introduce the pocket chart to the group. Be sure to explain the privacy of voting using this method.

Demonstrate many times with different participants showing how different answers would be represented until you think that the participants fully understand how to vote. Ask participants to take turns voting.

Activity Question: • Last time you defecated, how did you wash your hands?

Give each participant 1 rock to place in a pocket. Hang the chart where others cannot see the voting. Dismiss participants 1 at a time so each can vote privately.

After everyone has voted, record the votes on a hand-drawn graph similar to the pocket chart. Add each column together, totaling the male and female results.

Activity Questions: • Which way of handwashing was most common? • Which way of handwashing was least common? • How many people washed their hands using ash or soap altogether? • How many people did not wash their hands at all? • Why do you think they did not wash their hands?

Explain that when using a pocket chart in a community, it is important to instruct people how to vote. It is also important to demonstrate the voting procedure then ask volunteers from the community to demonstrate voting until you know that they understand how to do it.

What can we learn using a pocket chart that we may not be able to find out in a baseline survey or in a focus group?

Discussion Questions: • Do you have any questions about pocket chart voting? • What information can we find out using pocket charts that we may not be able to find out using a household survey or a focus group? • How do you think this method of voting would work in the communities in which you work? • If so, what are some other things you could find out using a pocket chart? • Can you make a pocket chart? • Will you actually make a pocket chart? o Or is there a different system that would still protect privacy?

80 mWASH Manual Framework for Change Lesson 3.10 Adapting Attitudes

Lesson 3.10: Adapting Attitude

Purpose of Lesson: • To understand the importance of cultural and personal attitudes and how they can impact a WASH program Objectives: • To consider what barriers prevent people from changing their behaviors • To examine one barrier to handwashing with soap- the perceived high cost of soap- and how it can be overcome • To brainstorm different benefits of WASH that people value highly Materials: • Piece of paper for each participant present • Lots of small rocks to use in the cost demonstration • Bibles Preparation: 1. List the aspects of “Attitude” on a flipchart for reference: a. Believed benefits b. Believed costs c. Believed severity d. Believed risk e. Other people’s attitudes f. Religious beliefs, cultural traditions, values, history, lifestyle Time: 60 minutes

Background • Learning what people think and feel about a water, sanitation or hygiene behavior can help us know how to promote this behavior better. What people want in regards to water, sanitation and hygiene for themselves, their family, and their community motivate them to acquire these things. • Attitude: A way of thinking, believing or feeling about something o Attitude is often influenced by tradition, culture, and a person’s family or peers o Attitudes are impacted primarily by 5 factors: § Believed benefits: The positive results someone thinks something will provide. This is how someone feels, regardless of whether it is true or not. These benefits could be financial, social, religious, time-related, or other. § Believed costs: The negative results someone thinks something will have. This is also how someone feels, regardless of whether it is true or not. These costs could be financial, social, religious, time-related, or other. § Believed severity: How big someone thinks the cost or reward of an action will be. § Believed risk: How likely a person believes a cost or reward associated with an action will be. § Other people’s attitudes: The attitudes especially of their peers and the attitude of people they believe are experts.

81 mWASH Manual Framework for Change Lesson 3.10 Adapting Attitudes

o Examples of attitudes: § Handwashing will make me prettier. § People will think I am rude if I wash my hands before eating their food. § Open defecation rarely causes diarrhea. § Spirits are able to protect me from disease. § My schoolteacher says it is important to use a latrine. § It is traditional for people to wash hands in the same bowl before eating together, this is a sign of unity and friendship.

82 mWASH Manual Framework for Change Lesson 3.10 Adapting Attitudes

1. Introduction Learning Activity: 15 minutes

Ask each person to write down in their notebooks a short list of what they value most in their lives (ex: social status, respect from peers, money, religion, education, health). Then in pairs write another list of the values of the community members with whom they work, to the best of their knowledge.

Activity Questions: • Is this information valuable to know before beginning a WASH program? • How might these values affect the communities’ WASH behaviors or desire to change their behavior?

2. Brainstorming Attitudes: 30 minutes

Explain further what attitude is and what different factors can affect attitude, using the information in the Background section. Post the Attitude flipchart on a wall for reference. Then introduce the next activity by explaining that it is especially important to understand people’s attitudes towards behaviors that we want them to change. 3 behaviors we have already learned about which improve health are 1) Treating Water to Make It Safe, 2) Latrine Use, and 3) Handwashing with Soap or Ash. It is necessary to take some time to think about what attitudes, good or bad, community members have toward these behaviors.

Divide participants into 3 groups. Each group will gather around 1 of the 3 flipcharts (treating water, latrine use, handwashing with soap/ash) to brainstorm what different attitudes (good or bad or neutral) community members have relating to that activity. They will write down as many ideas as they can think of. After 5 minutes groups move to a different flipchart and continue to add new ideas. They will brainstorm on the second flipchart for 3 minutes, and then the third flipchart for 2 minutes (timing is flexible). After giving groups a couple minutes to review their original topic and the ideas others added, have each group present the list of attitudes toward their topic to the rest of the group. Lead a discussion using the questions below.

Discussion Questions: • Which of these do you think could support people’s desire or ability to practice healthy WASH behaviors? • How can we promote these benefits in communities? • Which of these do you think could be a barrier to people’s desire or ability to practice healthy WASH behaviors? • What might happen if we tried to teach these behaviors without finding out what the community’s attitudes toward them are?

3. Optional Activity: Barriers to Using Soap: 15 Minutes

Explain that we are now going use the example of 1 common barrier to handwashing and how the barrier can be overcome. This is an activity that can be done in communities.

83 mWASH Manual Framework for Change Lesson 3.10 Adapting Attitudes

Introduction Learning Questions: • Do you know anyone in the community who does not want to use soap for handwashing because it is too expensive?

Demonstrate how using soap to wash your hands can actually help a family save money over time. Show the costs involved with buying soap by using rocks or bottle caps to represent money. As each cost is added, add more rocks.

Step 1: Ask the participants how much a bar of soap costs. Show this cost in rocks or bottle caps. Place them on the ground in front of you. Step 2: Ask the participants how many bars of soap they would need for a month of handwashing. Add more rocks to represent each bar of soap needed. Step 3: Ask the participants how much it costs to take a child to the clinic to treat diarrhea. Begin a new pile and add rocks to represent this cost. Step 4: Ask participants to then think about the additional costs involved in a trip to the clinic such as the cost of medicine, time, transport, loss of income etc. For each additional cost, add the appropriate amount of rocks. Step 5: If one takes their child to the clinic several times a month, this cost would increase several times. Add 2 times the amount of rocks to the pile to show the total costs.

Explain to participants that if they spend their money on buying soap (the smaller pile of rocks), they will be less likely to have to spend a larger amount to take their child to the clinic to treat diarrhea (the larger pile of rocks). The cost of not using soap can be much greater than the cost of using it.

Discussion Questions: • How can using soap help you save money over time? • What would you rather spend your money on? A few bars of soap or a visit to the clinic? • How would people respond to this demonstration?

4. Optional Activity: Spiritual Connection: 15 minutes

Explain that behavior change can be a difficult process, both for the development worker and for the community member. Then have volunteers read the verses below and use the questions to facilitate a discussion of the role of the Holy Spirit in behavior change. • Philippians 4:13 “I can do all things through Christ who gives me strength.” • Ephesians 3:16 “I pray that out of his glorious riches that he may strengthen you with power through his spirit in your inner being.” • John 16:13 “When he, the spirit of truth comes, he will guide you into all truth.” • “The LORD himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged." -Deuteronomy 31:8 (NIV1984)

Activity Questions: • What is the role of God’s power and the Holy Spirit in change? • What are ways we can encourage community members as they try to change their behavior? • What are ways that we can be sure to rely on God’s power and strength rather than our own as we implement our programs?

84 mWASH Manual Program Strengthening Section 4

Section 4. Program Strengthening

Next we will consider how to incorporate all of the lessons we have learned into our WASH program. There has been a lot of information covered in this course and it can be overwhelming. Unless we stop now and plan for how to strengthen the program using the information and insights we have gained, then it is easy to carry on with our tasks each day without applying what we have learned.

Let’s pause now, discuss the program that has been planned, and think through the ways that the program can be strengthened considering what we have just learned.

85 mWASH Manual Program Strengthening Lesson 4.1 Strengthening Questions

Lesson 4.1: Strengthening Discussion Questions

Purpose of Lesson: • To improve the quality of the WASH program using information and strategies learned in the mWASH course Objectives: • To review the WASH program that has been planned • To discover issues which need to be incorporated into the program Materials: • A piece of paper for each participant

Preparation: AT LEAST TWO DAYS PRIOR 1. Select a local representative to present an overview of the program to the participants. 2. Work with the representative to help them know what to discuss using the Background section.

Time: 1-3 hours

86 mWASH Manual Program Strengthening Lesson 4.1 Strengthening Questions

1. Intro Activity: 15 minutes

One of the leaders of the participating organization or of the local community development work will give an overview of the WASH program. Some of this may be a review of known strategies and activities, and some may be new information of how certain strategies will be conducted, such as Community Triggering and Total Sustained Change.

2. Participant Planning Time: 1 hour

Depending on the leader’s plan for this section, have participants brainstorm the following questions to plan how they will implement the changes discussed throughout the training.

Strengthening Questions: Community Triggering

• What does it look like to implement CLTS in this program? • How will this program create an immediate awareness of the problem of poor sanitation? • How will this program create community-wide desire to change sanitation habits? • What is the plan for follow-up and monitoring of CLTS?

Sustained Transformation • Which key actors will this program use? • What will the key actors do? o How will these key actors promote WASH within their areas of influence? o Are there any new key actors that we should consider including in the program? (see the group of key actors set aside as possible key actors in Lesson 3.7) • How will program staff train these key actors? • How often will staff follow up with key actors to help them overcome challenges, improve on successes, learn from one another, and stay encouraged? • Are there any other ways we can strengthen the sustainability of behavior change?

Strengthening Questions: General Program • What barriers to WASH did we identify that need to be addressed in order to successfully change behavior in the communities? o How will we overcome these barriers? • What benefits of WASH did we identify that need to be promoted? o How will we promote these benefits? • In what ways is this program working to transform people’s relationship with God? • In what ways is this program working to transform people’s relationship with each other? • In what ways is this program working to transform people’s relationship with the environment?

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Appendix

Appendix 1: Key Community Development Holism Flipchart Examples

Passage Physical Spiritual

Matthew 10:42

Matthew 9:1-8

Matthew 12:9-13

John 5: 5-14

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Appendix 2: Sugar Salt Solution Recipe and Directions

Materials: • Flipchart • Safest water available (enough for all participants) • Sugar or sugar substitute (honey, brown sugar, fruit juice) (enough for all participants) • Salt (enough for all participants) • Clean cups (enough for all participants) • A clean utensil for stirring water (stick, spoon, or another cup)

Ingredients: • One cup, as clean as possible • A little bit of salt • A little bit of sugar: if no sugar is available, use honey, brown sugar, or fruit juice • Water: Use the safest water you have readily available. It is best to use boiled and cooled water. But don’t wait to make the recipe if you don’t already have water boiled. Use the safest water you have the first time you make it. Then, boil water for all future solutions.

Directions: 1. Always wash your hands first. 2. Fill a cup with 250-300ml water. 3. Add a two-finger pinch of salt to a clean glass of the safest water you have available. Demonstrate picking up the salt using your thumb and second finger. Add about 1.5gms salt to 250-300ml of water. Always put salt in first so that you can taste if the solution is the right level of saltiness. It is difficult to tell the salt level after sugar is mixed in. 4. Taste the drink. If it is saltier than your tears, throw it out and start over. Too much salt is dangerous. 5. Add a palm of sugar – no bigger than your thumb. Demonstrate putting sugar in your cupped hand, about 20gms to salty water. 6. Mix until you cannot see the salt and sugar anymore. Stir with stir sticks or pour back and forth between two clean containers. 7. Drink slowly. Finish the whole cup or glass.

Follow these instructions for drinking the solution: For INFANTS- Use a cup or spoon to slowly feed them 1/4 to 1/2 cup (125-150ml) after every time they have diarrhea.

For CHILDREN- Slowly feed them one cup (250-300 ml) after every time they have diarrhea.

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For ADULTS- Slowly have them drink two cups (500-600ml) after every time they have diarrhea.

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Appendix 3: Tippy Tap Instructions

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Pierce a hole on top of Turn the jug around so Pierce two holes about the jug handle. that you are facing the three fingers apart. opposite side from the handle.

Run a string between Tie the two ends of the the two holes. string to a stick to suspend the jug.

Thread a string through Tie a string around the Fill tippy tap with water a piece of soap and neck of the bottle and and pull loop to begin hand that from the jug make a loop at the end of washing hands. handle. the string.

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Appendix 4: Alternative Water Purification Methods

WaterGuard Method28: 10 Minutes

Before teaching this lesson: • Make sure this method is appropriate for the area. If Water Guard is not available in the area, this method may not be appropriate. • It is important to teach the instructions that come on the package of Water Guard. If these instructions differ from the instructions below, follow the package’s instructions. Demonstrate this method using locally available materials. If water is clear, pour 1 capful of WaterGuard into 5 gallons (20 liters) of water. If water is cloudy, pour 2 capfuls of WaterGuard into 5 gallons (20 liters) of water. Stir the water well with a clean utensil. Cover the water, Wait 30 minutes before drinking the water.

Discussion Questions: • Do you have any questions about WaterGuard? • Would this method be easy or hard to do in this community?

PuR Method29: 10 Minutes Background • The water purification packet was developed by P&G in collaboration with the U.S. Centers for Disease Control and Prevention (CDC). • Removes more than 99.99999 percent of common waterborne bacteria (including those that cause cholera), 99.99 percent of common waterborne viruses (including those that cause hepatitis A) and 99.9 percent of protozoa.

Before teaching this lesson: • Make sure this method is appropriate for the area. If PuR is not available in the area, this method may not be appropriate. Demonstrate this method using locally available materials. Use a PuR packet from the community in order to demonstrate how to make water safe. Pour entire package into ten liters of water. Stir well for five minutes. If the water is not clear, stir again. Cover the top of another clean water storage container with thick cotton cloth without holes. Use a small rope to tie the cloth down. Pour the water through the cloth. Collect the material on the cloth and dispose of it away from children and animals. Wait for twenty minutes before storing or drinking the water.

Discussion Questions: • Do you have any questions about the PuR Method? • Would this method be easy or hard to do in this community?

SODIS Method30: 10 Minutes Background • Bottle Material: Plastic bottles made from PET are recommended for SODIS use as they should not contain substances hazardous to health. Good transmittance of UV-A light is required when glass

28 http://www.cdc.gov/cholera/pdf/posters/2013/water_treatment_waterguard_SEAsia_508.pdf 29 https://www.csdw.org/csdw/pur-packet-technology.shtml 30 http://www.sodis.ch/methode/anwendung/index_EN

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bottles are to be used for SODIS. PET bottles are usually labeled as such, but they are not called by the same name in all countries. The bottles must be transparent and colorless. PET bottles often have a bluish tinge. This is not a problem. Heavily scratched bottles must be replaced. • Bottle Size: The bottles must not hold more than three liters. • Water Turbidity: If the water is very turbid, the effectiveness of the method is reduced. It is very easy to determine whether the water is sufficiently clear: o The filled PET bottle must be placed on top of a newspaper headline. Now one must look at the bottom of the bottle from the neck at the top and through the water. If the letters of the headline are readable, the water can be used. If the letters are not readable, the water must be filtered. This test corresponds to a turbidity of 30 NTU. • Weather: Cloudiness affects the strength of solar radiation and thus also the effectiveness of the method. Rule of thumb: o If less than half of the sky is clouded over, six hours will be enough to completely disinfect the water. o If more than half of the sky is covered with clouds, the bottle must be placed in the sun for two consecutive days. o The method does not work satisfactorily during lengthy periods of rain. On these days, we recommend collecting rainwater.

See Appendix 3: SODIS Diagram Before teaching this method: • Make sure this method is appropriate for the area. If two liter, clear, non-tinted water bottles are not widely available in the area, this method may not be appropriate. Demonstrate this method using locally available materials. Get a two-liter, clear water bottle with no labels from the community in order to demonstrate how to make water safe through the SODIS method. If collected water is not clear, filter the water through a cloth. This can be done by pouring water into a container covered by a clean, tightly woven cloth folded in half. The cloth will catch all the large material and the water that passes through will be clearer. Demonstrate how to wash the two liter plastic bottle with soap and water. Fill the bottle with the filtered water. Set the bottle out in the sunlight for six hours. Make sure to put the bottle in a place where there will not be any shade at any time of day. A good place is a metal roof. If the sky is cloudy, leave it out for two days instead. After this amount of time, the water is safe to drink.

Discussion Questions: • Do you have any questions about the SODIS Method? • Would this method be easy or hard to do in this community?

Filtering Water to Reduce Cholera or Guinea Worm31: 10 Minutes

Before teaching this method: • Make sure that large parasites in the water like cholera or guinea worm are a problem in this community. If these diseases are not common in the community, do not demonstrate this method. Demonstrate this method using locally available materials. This method of filtering water will only remove large parasites like cholera or guinea worm from the water. This method alone will not clear the water of most diarrhea causing germs. Using a cloth, water container and rope, demonstrate the process of filtering water. Fold a large, clean cloth 7-8 times. Cover the top of a water container with the folded cloth folded.

31http://www.sswm.info/sites/default/files/reference_attachments/CAWST%202009%20HWTS%20Fact%20Sheet%20S training%20Academic.pdf

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Use a rope to tie the cloth down. Pour the collected water through the cloth. The cloth prevents large germs such as cholera bacteria and guinea worms and their eggs from passing through. Only the water and smaller germs will be able to get through the cloth. Take the cloth off and clean it with soap and water. Let the cloth dry in the sun to kill all the germs left on it.

Discussion Questions: • Do you have any questions about filtering water? • Would this method be easy or hard to do in this community?

Chlorine Purification Method: 10 minutes

Before teaching this lesson: • Make sure this method is appropriate for the area. If chlorine tablets are not available in the area, this method may not be appropriate. • It is important to teach the instructions that come on the package of chlorine tablets. If these instructions are not available, follow the generic instructions32 below. Demonstrate this method using locally available materials. Use chlorine tablets available in the community in order to demonstrate how to make water safe. First33, allow water to sit until dirt has settled to the bottom. Cover a separate clean container with a clean cloth, folded 7-8 times and tied tightly over the container. Pour only the clear water into the second container, leaving behind the dirty water that has settled to the bottom. Carefully remove the cloth, wash it with soap and water, and dry in the sun. Add one tablet into one liter of water. Stir well for five minutes. Wait for thirty minutes before storing or drinking the water.

Discussion Questions: • Do you have any questions about chlorine purification? • Would this method be easy or hard to do in this community?

32 http://water.epa.gov/aboutow/ogwdw/upload/2006_09_14_faq_fs_emergency-disinfection-drinkingwater-2006.pdf 33 http://www.cdc.gov/healthywater/emergency/safe_water/personal.html

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Appendix 5: SODIS Diagram

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Appendix 6: Triggering Activities - Transect Walk34 CLTS – Triggering Stage

Purpose of Lesson: • To initiate awareness of the occurrence of open defecation and feelings of shame toward it Objective: • Present triggering activity to participants Materials: • None Preparation: 1. Be familiar with transect walk and facilitation questions. Time: • Preparation 15-30 minutes • Presentation 30 minutes

Background • Transect walks are the single most important motivating tool. The embarrassment experienced during this ‘walk of disgust’ can result in an immediate desire to stop open defecation and get rid of these areas. Even though everyone sees the dirt and shit every day, they only seem to awaken to the problem when forced by outsiders to look at and analyze the situation in detail. • A transect walk involves walking with community members through the village from one side to the other, observing, asking questions, and listening. • The key sites to be visited include household toilets, backyards, water points, roadside bushes, ditches, burial grounds, and institutions such as schools, health posts/centers, market places, and places of worship. • During a transect walk for CLTS you could locate the areas of open defecation and visit the different types of latrines along the way. Try to understand with the community what constitutes an ‘unhygienic’ latrine. Visit latrines which are not covered or where the feces are draining out in the open. Flash a torch through the hole of open pit latrines and ask some people to look inside and say what they see. Ask if flies were being produced inside the pit and if it was it safe to leave the pit open. • The key is standing in the open defecation (OD) area, inhaling the unpleasant smell and taking in the unpleasant sight of shit lying all over the place. If people try to move you on, insist on staying there despite their embarrassment. Experiencing the disgusting sight and smell in this new collective way, accompanied by a visitor to the community, is a key trigger for mobilization. • If time, have community share areas they are proud of.

34 Adapted from: Kar, Kamal. Handbook on Community Led Total Sanitation. Plan International. March 2008. 27

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Transect Walk: 30 minutes

Conduct a transect walk with the community members using the information provided in the Background section. Walk through the community with them from one side to the other and visiting key sites listed in the Background section. When visiting the OD area, stay for a while despite embarrassment. End the walk in a large open area where the next activity – Community Mapping – will take place immediately following the Transect Walk while community members are still gathered together.

Activity Questions for OD sites: • Whose shit is it? • Which families use such areas for defecation? • Where do women go to defecate? • What happens during emergency defecation at night or during high incidence of diarrhea? • What constitutes an ‘unhygienic’ latrine? • What do you see inside the latrine? • What do you see in the pit? • Does it smell bad? • Are flies being produced inside the pit? Where do they go when not in the pit?

End the Transect Walk in a large open space for the next activity – Community Mapping.

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Appendix 7: Triggering Activities - Community Mapping35 CLTS – Triggering Stage

Purpose of Lesson: • To create awareness that open defecation is a big problem Objective: • Present triggering activity to participants Materials: • Tools to draw or outline the map. These could be sticks, thread, etc. • Cards or other item to mark homesteads • Yellow powder or some noticeable marker to show open defecation areas (The marker should be easily visible and show amount of feces present) Preparation: 1. Be familiar with community mapping and facilitation questions. Time: • Preparation 15-30 minutes • Presentation 30 minutes

Background • Facilitate the community to make a simple map on the ground showing households, resources, defecation areas, water points and problems, to stimulate discussion. Ask them to choose a suitable large open area for this. The mapping gets all community members involved in a practical and visual analysis of the community sanitation situation. In the mapping exercise, all households should be invited to locate their dwellings on the map, for example by marking the ground, or locating a leaf or stone, and to show whether they have a latrine or not. The areas of open defecation can be shown with a colored powder, and lines drawn to connect them to the households that visit them. The map can be used to highlight many things. Draw attention to how far some people have to walk to defecate and at what times of day and safety issues. Ask people to trace the flow of shit from places of open defecation to ponds and other bodies of water, resulting in their contamination. • Steps: 1) Do not hand out materials to community member, rather place them in a convenient area and have the member get them themselves. You don’t need many resources to make a map. Encourage participants to use leaves, seeds, sticks or other easily available materials to represent different things. Encourage creativity and make it fun. 2) During the mapping exercise, ask the community to stand in small groups according to their respective neighborhoods. Ask them to discuss among themselves which is the dirtiest neighborhood of their village, the second dirtiest and so on, and to note these on a piece of paper. Collect and read out the papers. In most cases you will find that all groups identify the same 1 or 2 neighborhoods as the dirtiest. 3) Then ask the groups to note down where they go to defecate. Through this exercise people of the dirtiest neighborhood realize, maybe for the first time, that others are defecating in their areas and are also labeling them as the dirtiest neighborhood. This discovery usually triggers immediate action to stop strangers from coming into their areas to defecate. After this realization, the poorer and lower status people in many villages prove to be the most active and fastest initiators of CLTS. They also benefit most from saving money spent on treatment of diarrhea and other diseases.

35 Adapted from: Kar, Kamal. Handbook on Community Led Total Sanitation. Plan International. March 2008. 30

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1. Draw Village Boundary: 5 minutes

As you end the Transect Walk, ask community members to come and stand around a large open space (preferably the space should be clean and dry with no rubbles, stones or grass.) Invite a few volunteers to draw a quick boundary of the village.

2. Indicate Landmarks: 5 minutes

Ask someone new to indicate only a couple of important landmarks (such as school, main road crossing, and places of worship inside the boundary).

Now ask someone to step inside the map and indicate the place where they were all standing (today’s gathering).

3. Identify Individual Homes: 5 minutes

Identify a young boy or girl and ask him or her to step in and indicate his or her house Ask the gathering if he/she did it correctly. If correct, ask everyone to give him/her a thunderous clap. All these help everyone to get orientated with the map.

Very clearly explain the following to everyone: • Only 1 member from each family should pick up a card (heaps of card should be kept outside the map) and walk inside the map and stand exactly on the spot where his/her house is located. • Allow some time for the people to settle down on the map properly • Now ask them to write down the name of the head of the family on that card and place it on the location of the house (near his/her feet where he/she was standing)

4. Identify Defecation Sites: 15 minutes

Tell them that these cards represent their houses. Now ask them to draw a line from their respective houses to the place where they go to defecate. Tell them to use chalks to draw lines on the ground connecting their houses to OD places. At this point there will be lots of laughter and fun.

Allow the same to happen. Remember you should not hand out cards or chalks one by one to the community. Keep these materials in a corner of the map and ask them to go and collect it. Encourage a lot of movement and fun creativity.

Indicating the plastic/paper bag containing the yellow powder or other method of identifying OD sites, tell them to pick up and show the respective places of open defecation indicating their shit. Tell them to spread more yellow powder where there is more shit and less vice versa. There will be much more laughter at this stage.

Remember not to bring the bag of yellow powder from person to person. Let them do it all. You will notice a big rush to pick up a handful of the yellow powder. At this point children will pour yellow powder in places henceforth unknown to many parents.

Now ask every one to come back and stand on their house positions again.

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Activity Question: • Where do you go for emergency defecation? Meaning during rains, in the middle of the night, at times of severe diarrhea or when sick and so on.

Ask them to pick up yellow powder and put some on these spots of emergency defecation. You will find another round of laughter and people additional heaps of yellow powder around their homestead. People might say that during emergency they go behind the house of their neighbor and similarly his neighbor comes to shit behind his kitchen garden. Everyone will notice that the map is gradually turning yellow. You can ask them whether the entire village seemed to be full of shit.

Have the group step outside the boundaries and look over their map.

Activity Question: • What are your reactions?

Remain standing around the Community Map for the next activity – Shit Calculation.

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Appendix 8: Triggering Activities - Shit Calculation36 CLTS – Triggering Stage

Purpose of Lesson: • To create awareness of how many feces are in a community Objective: • Present triggering activity to participants Materials: • Community map from previous activity • Markers to write on cards • Flipchart Preparation: 1. Be familiar with shit calculation activity. Time: • Preparation 15-30 minutes • Presentation 30 minutes

Background • Calculating the amount of feces produced can help to illustrate the magnitude of the sanitation problem. • This activity should be done immediately after Community Mapping • Never suggest to stop open defecation or to construct toilets. You are not supposed to suggest or prescribe. • You can do the calculation of shit by households on the same map the community made.

36 Adapted from: Kar, Kamal. Handbook on Community Led Total Sanitation. Plan International. March 2008. 33

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1. Begin Shit Calculation: 15 minutes

While still standing around the Community Map, ask the following question:

Activity Question: • How much human excreta is being generated by each individual or household per day?

Households can use their own methods and local measures for calculating how much they are adding to the problem. The sum of the households then can be added up to produce a figure for the whole community.

A daily figure can be multiplied to know how much shit is produced per week, per month or per year. The quantities can add up to a matter of tons, which may surprise the community.

Ask which household produces most, and ask everyone to clap and congratulate the family for contributing the most shit to the village. Similarly identify the second, third and so on and appreciate their contributions. Identify the family that produces the least. Ask them why they produce so little shit? Ask them to eat more and shit more. All this generates a lot of fun but silently the fact emerges clearly.

2. Discuss Health Costs: 15 minutes

Ask people how much they spend on health treatment. Stand around the map. Point out the cards and ask them how much they spend for treatment and medicine for diarrhea, dysentery, cholera and other OD-related diseases they identified. Ask whether they wish to calculate by month or each year, and then to write the amount on their household card only using markers

As with calculation of feces, ask which family spends most. Point it out if they live close to the defecation area or in the dirtiest neighborhood. Are they poor or rich? Who suffers most – rich medium or poor?

Put up flip chart and ask them to calculate how much the whole community spends in a month, a year, and then over 10 years. Put this chart next to the calculation of amounts of shit by month, year and 10 years.

Discussion Questions: • Does any poor families have to borrow money for emergency treatment of diarrhea for a family member? • If so, how much? From whom and where? • Was it easy to borrow money and repay it? • Who lends money for emergency treatment and at what rate of interest? • NGOs, middlemen?

Remain in the same location for the next activity – Feces Flow Diagram.

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Appendix 9: Triggering Activities - Feces Flow Diagram37 CLTS – Triggering Stage

Purpose of Lesson: • To create realization that people are eating their and their neighbors’ feces Objective: • To present triggering activity to participants Materials: • Markers to write on cards • Flipchart • Glass of water • Strand of hair or blade of grass • Shit Preparation: 1. Be familiar with flow diagram and glass of water activity. Time: • Preparation 15-30 minutes • Presentation 30 minutes

Background • This activity takes place immediately after Shit Calculation. • The objective of the Flow Diagram is to discuss the role of running water, chicken and birds, flies, people, cattle and other animals, wind, etc. in contaminating the surrounding air, food and drinking water. • The purpose of the Glass of Water exercise is to let the community to know, in a concrete way, that they are eating and drinking each other’s shit. This exercise is the climax of the whole issue of Transect Walk, Community Mapping, Shit Calculation and Flow Diagram. This exercise will show them the invisibility of the feces entering their water.

37 Adapted from: Kar, Kamal. Handbook on Community Led Total Sanitation. Plan International. March 2008. 35

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1. How Shit Gets into Homes: 5 minutes

Immediately after calculating all the shit in the community, ask the following question:

Activity Question: • Where does all this shit go?

As people answer that it is washed away in rain, or enters the soil, draw a picture of a lump of shit and put it on the ground. Put blank cards and markers near it. Ask people to pick up the cards and draw or write the different agents or pathways, which bring shit into the home. For example: flies, rainwater, wind, animals, shoes, or children’s toys.

2. How Shit Gets into Mouths: 5 minutes

Activity Question: • How does shit get into the mouth?

For example: hands, nails, or utensils washing in contaminated water. You should never suggest the pathway of contamination. Let people discuss, identify, draw/write.

3. Glass of Water: 15 minutes

Then ask for a glass of drinking water. When the glass of water is brought, offer it to someone and ask if they could drink it. If they say yes, then ask others until everyone agrees that they could drink the water.

Next, pull a hair from your head and ask what is in your hand. Ask if they can see it. Then touch it on some shit on the ground so that all can see. Now dip the hair in the glass of water and ask if they can see any thing in the glass of water.

Next, offer the glass of water to anyone standing near to you and ask him or her to drink it. Immediately they will refuse. Pass the glass on to others and ask if they could drink. No one will want to drink that water.

Activity Question: • Why won’t you drink the water?

Relate the calculated amount of shit and the flow diagram and ask them whether they were eating/drinking shit

Activity Question: • How many legs does a fly have? • What happens when a fly with 6 legs sit on children’s food and plate? • So, what are you eating with your food?

When someone says that they are eating one another’s shit, bring them to the front to tell everyone. The bottom line is: everyone in the village is ingesting each other’s shit. Once one of the community members has said this publicly, you can repeat it from time to time. Do not say it before they do. It has to be what they have said as a result of their analysis, not what you have come to tell them.

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4. Calculate Shit Eaten: 5 minutes

Ask them to try to calculate the amount of shit ingested every day.

Activity Question: • What do you feel about eating others’ shit because of open defecation?

Don’t suggest any thing at this point. Just leave the thought with them for now, and remind them of it when you summarize at the end of the community analysis.

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Appendix 10: Alternative Community Triggering Option Part 1

Part 1: Effects of Open Defecation

Purpose of Lesson: • To learn about the effects of open defecation Objectives: • To learn about the effects of open defecation • To learn what the Bible’s view on open defecation is Materials: • Flipchart or large piece of paper • Markers Preparation: 1. Write Deuteronomy 23:12-14 on a piece of flipchart paper. 2. If doing the Drama: Choose 3 people to perform a drama about open defecation and the ways it can be embarrassing. Time: 60 minutes

Background • Open Defecation (OD) is a term used for when people relieve themselves in the open and leave the feces lying on the ground. When feces are left in the open, it can get on animals, humans or flies and can make you sick.

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1. Optional Activity: Drama about the Negative Effects of Open Defecation: 5 minutes

Choose 3 participants to perform a drama about open defecation and the ways it can be embarrassing.

Activity Questions: • What was happening in the drama? • Does this happen in your community? • How do you feel about feces lying on the ground?

2. The Effects of Open Defecation: 20 minutes

Start a discussion about the effects of open defecation. Use the Discussion Questions below to start this conversation.

Discussion Questions • How does open defecation affect people in a social or physical way? • How does open defecation affect the environment in a village?

3. The Bible’s Message on Open Defecation: 35 minutes

Listen to the following verse in the Bible about open defecation.

“Designate a place outside the camp where you can go to relieve yourself. As part of your equipment have something to dig with, and when you relieve yourself, dig a hole and cover up your excrement. For the LORD your God moves about in your camp to protect you and to deliver your enemies to you. Your camp must be holy, so that he will not see among you anything indecent and turn away from you.”

Deuteronomy 23:12-14

Activity Questions: • What do you hear in this verse? • Why do you think God wishes us to do this? • How does this change your perspective on open defecation?

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Appendix 11: Alternative Community Triggering Option Part 2

Part 2: Basic Sanitation

Purpose of Lesson: • To improve sanitation practices through better disposal of feces Objectives: • To identify the behaviors that their communities practice • To learn different options for disposing feces • To determine which method of feces disposal would work best in their community Materials: • Markers • Pieces of paper for drawing Preparation: 1. Gather all necessary materials. Time: 35 minutes

Background • Sanitation involves the act of safely disposing of feces. The goal of sanitation is to limit contact with feces.

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1. Ranking Local Practices: 15 minutes

Divide the participants into groups of 3-4 people and give each group a stack of blank paper. Instruct groups to discuss as a team different types of places that people defecate. Have groups use the paper they were given to draw each defecation place.

Facilitate a discussion using the Activity Questions below.

Activity Questions: • Which of these drawings represents the most common practice in this region? • What differences did you notice between the defecation places? • What was good about each method? What was not good? • In the future, which practices would be best for this region?

2. The Sanitation Ladder: 20 minutes

Allow participants return to the small groups they were in previously. Have each group consider amongst themselves the answers to the following questions:

Activity Questions: • Which drawing represents the most common practice that you use now? • In the future, which practices would you like to use?

Then, instruct participants to create a “Sanitation Ladder” that will allow each participant move from their current defecation place to the place they wish to defecate in the future. To make a sanitation ladder, order pictures from easiest place to defecate to more difficult or costly places to defecate. While completing this ladder, instruct participants to consider how they would go from the bottom defecation place to the next place, to eventually the more difficult place. Remind participants that transitioning from one defecation place to another does not have to be a big step, rather, it can be a small step.

Activity Questions: • What defecation place do you want to try in the future? • How can you work towards getting this defecation place? • How would this improve your sanitation? • What is something simple you could do today to help reach this goal?

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Appendix 12: Focus Group Discussion

Definition: Discussion with small groups of relatively similar people asked to reflect on the facilitators’ questions, provide their own comments, listen to what the rest of the group has to say and react to their observations. It requires a skillful facilitator guiding the discussion, cross-checking each participant’s comments, and ensuring an even participation from all members.

Focus group discussions are a great way to hear about a subject from the people in the group. They especially help to find out what people really think and why they may think that way.

Key things that are needed for a focus group discussion are:

• Clear objectives • A well thought-out discussion guide • A moderator who allows the participants feel comfortable • A determination to find out what people really know and think

Materials: a facilitator to ask questions and another one to record responses, paper and pen for recorder to take notes on discussion, filled out focus group discussion guide

Estimated Time: 1-2 hours, focus group discussions should never go over 2 hours

Steps:

Before the focus group discussion

• Decide on the objectives of you focus group discussion. • Make a first draft of your discussion guide. Get a team member who knows the community best to propose how to phrase the questions. Improve and revise the guide together. (You may use the 2 guides included in these instructions if desired. Add questions to the guides if you want to gather more information.) • Choose a location that is convenient for your participants where you won’t be disturbed too much. • Invite about 6-12 people who are representative of your target group. • Select a group with similar backgrounds so that everyone feels at ease to say what they think with the others and everyone feels equally concerned. • Prepare the meeting: arrange for chairs, refreshments, writing materials or tape recorder, batteries and cassettes if you decide to use them. • You need at least 2 people to carry out the focus group discussion; 1 facilitator and on recorder.

Just before the focus group discussion

• Arrive to the location before the participants. • Arrange chairs in a circle so that everyone can see each other. Set up refreshments and other materials if necessary.

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During the focus group discussion

• Introduce yourselves and explain the reason for the meeting. • Use a tone of voice and body language that puts everyone at ease. • Use the local language if possible. • Include everyone in the discussion, don’t allow any 1 person to dominate. • Don’t accept just the first answer but probe until you get to the bottom of what really motivates their behaviors. • Notes need to be as close as possible to what was actually said by the participants. • The discussion should last about an hour, and never longer than 2 hours.

After the focus group discussion

• Write up a full and complete transcript of what was said by the participants. • The transcript is your data. It should be carefully saved for future reference. • Go back to your questions. Record what was said in each discussion on a given subject.

What to Record: After the activity, take time to record what you learned about the participants and their community. Specifically note what you learned about what people know, do, and want.

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