CHV Facilitators Guide Module7 Wash PDF

Facilitators Guide
MINISTRY OF HEALTH
7
COMMUNITY HEALTH VOLUNTEERS (CHVs) MODULE
WATER, SANITATION
AND HYGIENE
Division of Community Health Services

“Afya Yetu, Jukumu Letu”
COMMUNITY HEALTH Module No. 7
VOLUNTEERS (CHVs) Water, Sanitation
Facilitators Guide and Hygiene
This publication is made possible by the generous support of the Government of Kenya and United States Agency for International
Development (USAID). The contents do not necessarily reflect the views of USAID, the United States Government or the Japanese
Government.
June 2013
List of Abbreviations
AICAD The African Institute for Capacity Development
AMREF African Medical Research Foundation
CHEW Community Health Extension Worker
CHSFP Community Health Strategy Focal Person
CHV Community Health Volunteers
CLTS Community Led Total Sanitation
DCHS Division of Community Health Services
FHI 360 Family Health International
JICA CHS Japan International Corporation Agency- Community

Health Strategy project
MDGs Millennium Development Goals
MOH Ministry of Health
NGO Non-Governmental Organization
NHSSP National Health Sector Strategic Plan
PET Polyethylene Terephthalate
PVC Polyvinyl chloride
SODIS Solar Water Disinfection
STI Sexually Transmitted Infections
TB Tuberculosis
UNICEF United Nations Childrens Fund
USAID United States Agency for International Development
UTI Urinary Tract Infection
WASH Water, Sanitation and Hygiene

Table of Contents
List of Abbreviations
Foreword ii
Preface iii
Acknowledgements iv
Contributors 1
Introduction and Purpose 2
Module 7:
Water, Sanitation and Hygiene 2
Unit 1
Water Safety 5
Importance of Water for Health 7
Improving Water quality in the Community 8
Causes of Water Contamination and Health Problems
caused by Unsafe Water 9
Water Treatment at Household Level 17
Water Treatment Methods 19
Safe Water Storage 22
Unit 2
Sanitation 25
Purpose and Objectives of this Unit 26
Definition of Sanitation 26
Components of Sanitation and the Sanitation Ladder 27
Health Problems Caused by Poor Sanitation 37
Environmental Sanitation 38
Unit 3
Hygiene 41
Purpose and Objectives of this Unit 42
Definition of Hygiene 42
Types of Hygiene 43
Handwashing 45
Home and Food Hygiene 61
Bibliography 65
FACILITATORS GUIDE | COMMUNITY HEALTH VOLUNTEERS | MODULE NO. 7 | WATER, SANITATION AND HYGIENE i
Foreword
Health is a major component in the socio-economic development of any community.

Indeed, it is not only a right but also a responsibility for all. Promotion of good
health at different levels of society is the responsibility of all individuals, families,
households, and communities. Kenya has embraced the community strategy to
enable communities to improve and maintain a level of health that will enable them
to participate fully in national development towards the realisation of Vision 2030.
Extensive consultations among various departments, divisions and stakeholders

marked the development process of the Community Health Volunteer (CHV)
Curriculum and this Water, Sanitation and Hygiene (WASH) manual. The inputs from
the different groups was harmonised, and has informed the production of this manual.
This document will assist the Ministry of Health and the Division of Community
Health Services in achieving its strategic objectives as outlined in the National Health
Sector KHSSP3 and towards the attainment of Millennium Development Goals (MDG)
targets. It will be used to administer WASH training through well-trained Community
Health Extension Workers (CHEW).
In having a harmonised training manual, health managers will be able to guide CHVs
to efficiently offer services to communities, linking them to care and referral. This is
expected to boost awareness of availability of preventive and promotive services to
the communities, increased access and uptake of services.
On behalf of the Ministry of Health, I wish to thank USAID WASHPlus/FHI 360, UNICEF
and JICA CHS project who provided financial and technical support, and all other
contributors, reviewers and editors who worked tirelessly to produce this manual.
They made the preparation of this manual for the training of Community Health
Volunteers possible. I thank IntraHealth for supporting and following up on this work
which included the provision of the consultant who has facilitated the production of
this manual.
I am confident that the implementation of this manual will help us address the issue
of equitable access to primary health services and by so doing, bring about a much
improved status for all Kenyans that will be reflected in robust positive health indices.
Mark Bor, MBS

Permanent Secretary
P.S, Ministry of Public Health and Sanitation
Ministry of Health
ii FACILITATORS GUIDE | COMMUNITY HEALTH VOLUNTEERS | MODULE NO. 7 | WATER, SANITATION AND HYGIENE
Preface
One of the dominant themes in health policy and planning today is the need for
interventions based on sound evidence of effectiveness. The responsibility of ensuring
programmes are consistent with the best available evidence must be shared between
providers, policy makers and consumers of services.
CHVs have been major players in the implementation of primary healthcare since the
1980s, and still continue to play a critical role in mobilising communities in taking care
of their health, and providing basic healthcare at community level. To enable CHVs
be more effective and efficient in Water, Sanitation and Hygiene – there is need for
appropriate training, not only in community mobilisation but also in the assessment
of health-related issues in the community, and identification of appropriate actions at
that level. Such training needs to be well planned and implemented using a standard
training that takes into account the level of operation and capacity of CHVs. This also
requires the support of well-trained and informed trainers and supervisors from the
formal healthcare system.
This training is meant to assist the healthcare system at all the four tiers to
operationalize the community strategy by providing appropriate training for CHVs
to enable them take charge of appropriate interventions at tier 1. The Government
of Kenya is committed to supporting community health initiatives this way, and
accelerating the achievement of the current KHSSP III goals, MDGs and providing
support to Vision 2030.
The CHV training is organised in Modules which should be applied incrementally

to enable the CHVs develop adequate capacity for working with communities.
Specifically, the training covers two sections:
l Section One: Basic Modules
l Section Two: Technical Modules
This module on WASH is the seventh module to be developed after the six basic
modules.
It is my hope that all stakeholders in community health will utilise this manual to train
CHVs in order to standardise provision of healthcare to our communities.
Dr. Kepha Ombacho, MBS

Head, Department of Environmental Health
Ministry of Health
FACILITATORS GUIDE | COMMUNITY HEALTH VOLUNTEERS | MODULE NO. 7 | WATER, SANITATION AND HYGIENE iii
Acknowledgements
The development of this Facilitators Manual for training Community Health Volunteers
has been financed and technically supported by USAID through WASHPlus/FHI 360
and IntraHealth/Capacity project. For this, the ministry records deep appreciation and
gratitude.
The development of the Manual was preceded by extensive discussion by partners,

stakeholders and staff from different departments in the Ministry of Health (MOH)
as well as the Ministry of Medical Services. This culminated in the Technical working
Group’s retreat for the validation of this facilitators’ manual for training Community
Health Volunteers. Sections of this document have been adapted from MOH/USAID/
WASHPlus Training Manual for Community Health Workers on WASH-HIV Integration.
The following departments and divisions participated in the development of this
manual: Community Health Services, Malaria, Environmental Health, Nutrition, Oral
Health, Child and Adolescents Health, NASCOP, Reproductive Health, TB and Lung
Diseases, Departments of Health Promotion, Primary Health Care, Human Resource
and Training, Divisions of Vaccines and Immunization, Disease Surveillance and
Response and, Non-Communicable Diseases. Our appreciation goes to partners such
as USAID WASHPlus/FHI 360, UNICEF, AMREF and JICA CHS project who gave financial
and technical support.
We also recognize those who may not have participated directly in the drafting of
this manual but who rendered services in support of the teams that helped in its
realization. Last but not least, we thank communities who shared their experiences
that informed the development of this manual.
Special thanks are due to the participants at the development of the Community
Health Volunteers training manual workshop held at the Nakuru Resort in March 2012
and many meetings at AICAD. Many Thanks to Ms. Akiko Chiba of JICA CHS project,
the Capacity Unit members Mr. S.N. Njoroge, Ms. Jane Koech and Mr. Kenneth Ogendo
as well as the division staff who sacrificed to develop this manual.
Dr James Mwitari
Head, Division of Community Health Services
Ministry of Health
iv FACILITATORS GUIDE | COMMUNITY HEALTH VOLUNTEERS | MODULE NO. 7 | WATER, SANITATION AND HYGIENE
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Contributors
Various stakeholders and reviewers provided technical reviews and suggestions to

improve this module.
Following all input, this module was finalized. We acknowledge these contributors.
David K. Njoroge MOH-HRD Clare Mwangi MOH-DCHS
Akiko Chiba JICA CHS Project Kenneth Ogendo MOH-DCHS
John O Osir MOH-CHEW Anne Thitu MOH-DCHS
Ben Lodung’okiok MOH-CHEW Samuel N. Njoroge MOH-DCHS
Jacob Kioko MOH-CHEW Peter Wanjohi MOH Department of

Environmental Health
Josephine M. Nduva MOH-CHEW
Dr John Kariuki MOH Department of
Nickson V. Ouma MOH-CHEW Environmental Health
Georgiadis G. Mwambia MOH-CHEW Dr Kepha Ombacho MOH Department of

Tarcisio Nakuo Samburu CHSFP
Benjamin Murkomen MOH
Rhoda M. Makato Makueni CHSFP Department of
Sammy Kamwaro Kasarani CHSFP
Josephat Mutua Division of Child and
Rachel Kiiru Nairobi CHSFP Adolescent Health
Githinji Miginyo Nyeri CHSFP John Kagira USAID WASHPlus/FHI 360
Dr James Mwitari MOH-DCHS Evelyn Makena USAID WASHPlus/FHI 360
Samuel G. Kiogora MOH-DCHS Dennis C. Langat USAID WASHPlus/FHI 360
Jane Koech MOH-DCHS
FACILITATORS GUIDE | COMMUNITY HEALTH VOLUNTEERS | MODULE NO. 7 | WATER, SANITATION AND HYGIENE 1
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MODULE
Module 7
Water, Sanitation and Hygiene
Introduction
Purpose
The purpose of this module is to equip Community Health Volunteers with
knowledge and skills in water safety, sanitation and hygiene.
Key Community Practices l Understanding the sources of water in the community

addressed in this module
l Understanding sources of water contamination
l Protection of water sources
l Understanding the water treatment and practice methods
l Safe water storage
l Hand washing with soap, tippy taps, leaky tin practices
l Proper use of pit latrines and waste disposal
l Vector control for vector borne diseases
l To carry out health promotion activities including

Roles and Responsibilities
demonstration on all practices mentioned above in their
of CHVs in this module
communities e.g. Community Led Total Sanitation (CLTS)
l To identify water sanitation and hygiene related diseases
and to negotiate improved practices
l To identify root causes of the water and sanitation concerns
in the community and their solutions
Reference Wash Manuals e.g. wash modules
Number of Units Three

1. Water safety
2. Sanitation
3. Hygiene
Methodology Role-play, demonstrations, group discussions, stories,

brainstorming and mini lectures
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UNIT 1
WATER SAFETY
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Unit 1
WATER SAFETY
Objectives: By the end of the unit, the participants will be able to:
l Identify water sources and the ways of improving water quality
l Identify water contaminants and contamination routes
l Explain how to prevent water contamination
l Explain and demonstrate how to use different methods of making water
safe according to the situation
l Explain the dangers of using contaminated water.
Duration: · 7 hours 40 minutes
Methodologies: Brainstorming, discussion, demonstration and role-play.
Materials: Newsprint, Felt/Marker pens, Masking tape, Newspaper cuttings, Pens,

Notebooks, Training/Demonstration materials – Chlorine, Buckets,
Sticks/Mwiko.
Unit Session Plan

Duration Topics Methodology
20 min Purpose of this unit Story

and Objectives of this unit
10 min Importance of Water for Health Brainstorming
2 hrs Improving Water quality in the Community Discussion and

Group Work
(Village Mapping)
2 hrs Causes of Water Contaminations Group Work and

and Protection of Water Sources and Discussion
health problems caused by unsafe water
40 min Water Treatment at Household Level Discussion and

Demonstrations
2 hrs Demonstration of Water Treatment Methods Demonstration
30 min Safe Water Storage Group Work
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UNIT 1 : WATER SAFETY
ACTIVITIES AND FACILITATION STEPS
RActivity 1:
PURPOSE OF THIS MODULE AND OBJECTIVES OF THIS UNIT (20 MIN)
Starter Story to Learn Purpose of This Module and Objectives of this Unit
Read the following story of Timothy.
4
Timothy’s story
Njoki lived in the village of Kamwaki in Central province, Kenya, with her
young son Timothy. He was a happy and healthy child until recently.
In their village, water was pumped up from a deep borehole. A development

group had built the well and pumps many years before. Once in a while a
part of the pump would break, but one of the development workers always
knew how to repair it or could buy a new part. But now the development
workers are gone from the region. There is no one left who knows how to
repair the pump, and there is no money for new parts.
When the pump broke again, Njoki’s village had to rely on a water
hole far from the village. The water hole, also used by many animals,
was contaminated with, germs, and parasites (worms). Timothy soon
became very sick with severe, watery diarrhea. He became very weak and
dehydrated. Njoki had no money to take her son to the health centre many
hours away. Within a few days, Timothy died.
Ask participants, ”Why did Timothy die?” and discuss and identify the chain of causes of his death.
The following points should be answered during the discussion.
l What caused Timothy’s death?

l Why did he have diarrhea?
l Why didn’t Timothy’s family have enough safe water?
l Why didn’t Njoki make the water safer to drink?
l Ask participants whether there are similar situations in their community and what they want to
learn to improve the situations.
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Summarize the discussion and tell the participants. In this module we are going to learn to prevent
water and hygiene related diseases by promoting safe water and personal and environmental hygiene
practices in the community. So that, we can save the lives of children like Timothy and improve people’s
quality of life.
Share the objectives of the unit with participants.
RActivity 2:
IMPORTANCE OF WATER FOR HEALTH (10 MIN)
Brainstorm on Importance of Water for Health
Ask participants, ”Is water important to health? Why?”
As you list down their responses, check whether the key points in the following box are mentioned by
them or not and if not, add as you summarize their responses.
Key points: Water for Health

Water is essential for life. We need it, as do the animals and
plants that we depend on for our survival. In communities that
lack adequate water, many health problems arise.
l Without water, people cannot grow enough food to eat,

leading to malnutrition and the many health problems that
go along with it
l Infections of the eyes and skin arise when people cannot use
water to bathe. Other illness also spreads more quickly when
people cannot stay clean
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RActivity 3:
IMPROVING WATER QUALITY IN THE COMMUNITY (2 HRS)
Discussion and Group Work of Village Mapping for Improving Water quality
Ask participants, “In which activities in your life do you need water? How many litres of water do
you need for each activity per person?”
Copy the table below on flipchart and complete the table with the responses from the participants.
After completing the table, summarize.
Table to understand the amount of water a person needs/uses in a day
Drinking Food Personal Laundry Other Total

preparation cleanliness
& cleaning
Litres Litres Litres Litres Litres Litres
Summary on Amount of Water in Need for Life

A person needs 15 to 20 litres of water per day. But many people are forced
to manage with much less. Other needs, such as sanitation, irrigation and
watering livestock often require much more water than drinking, cooking
and washing.
Community places such as schools and health centres may need more than
the average amount of water used by one person in a household. Health
centres, for example, should have at least 40 to 60 litres of water per day
available for every person served.
l Group the participants according to their villages and tell them to draw their village map first on
the ground then transfer to the flipcharts
l The village map should include important landmarks such as roads, paths, houses and other
buildings, farms, fields, toilets and sewer lines, dumping sites, water sources people usually use
and unused water sources
l Allow two or three groups to present
l Discuss with participants whether there are any opportunities/ways to improve water supply
in their communities using the maps and if there are, how?
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Key points: Improving Water Quality

The actions your community takes to improve water security depend on
which problems are most urgent, or easiest to solve first. What is important
is to make a plan that addresses the root causes of the problems and satisfies
the needs of everyone in the community.
If water is scarce or difficult to get to, building rainwater catchment

tanks, storage tanks or a piped water system may help bring water closer
to the community. If this is not possible, can the work of collecting water be
shared to make it fairer and easier for everyone? If there already is a water
system, can the community improve it by improving collection methods,
fixing broken pipes and pumps, protecting water sources and conserving
water? If it is a problem that should be resolved by the government, can the
community solicit government support?
If the water is contaminated by germs, the source can be improved or

the water can be treated to make it safe. The community can discuss which
of these options will be easiest, most effective, and most sustainable over
time.
If the water may be contaminated by chemicals the water should not be

used until a water quality test can be done. If a test shows that the water
is contaminated, more contamination should be prevented and another
water source should be developed.
RActivity 4:
CAUSES OF WATER CONTAMINATION AND HEALTH PROBLEMS
CAUSED BY UNSAFE WATER (2 HRS)
Discussion on Causes of Water Contamination and the Ways of Protecting

Water Sources (40 min)
l Group the participants in each village (use the same groups made in activity 1) and ask them to tell
which water sources are safe and which are unsafe among the water sources indicated in the
village map. Ask them to tell the reasons why they think the sources are safe or unsafe.
l Ask groups, “Are there any actions to protect water sources from contamination taken by the
community and households? If yes, what are they?”
l If there are more possibilities to protect water sources from contamination other than the ones
described by the groups, explore the possibilities with participants.
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Key points: Protecting Water Sources

1. Ground water - shallow well, borehole, springs
Fencing, tree planting, covering using slabs and cement lining,
proper siting of toilets.
2. Rain water
Guttering system, cleaning the roofs and the gutters.
3. Surface water
Tree planting, fencing seating of toilets, avoid bathing in the
rivers, avoid cultivating along the rivers, constriction of animals
trough for drinking water, avoid car wash near the rivers.
4. Piped water
Avoid illegal connections and vandalism.
RActivity 5:
Brainstorming and Sharing on Health Problems caused by
Unsafe Water (1 hr 20 min)
Ask participants the following questions for brainstorming;
l Which health problems caused by unsafe water have you experienced and observed in your
community?
l When do these problems happen most?
l Why do you think these problems happen in the particular seasons?
l What do you do to manage the health problems caused by unsafe water?
l Divide the participants into groups and ask them to draw a chart to explain how diarrhea
diseases can spread
l Allow 3 or 4 groups to present and the others to input on the presentation.
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An example of the chart showing how diarrhea disease spread
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Share information in the following Resource Notes with the participants. Try to make the session as
interactive as possible rather than lecturing.
Ü
Resource Notes on Diarrhea Diseases
Diarrhea diseases
Diarrhea, dysentery, cholera, and typhoid are caused by many kinds of germs carried
by human waste, unsafe water, flies and insects, and on food. Diarrhea can be a sign
of some kinds of worm and parasite infections. These illnesses may also be caused by
poor sanitation and a lack of enough water for personal cleanliness.
Signs of diarrhea diseases

The most common sign of a diarrhea disease is frequent, watery stools. It may be
accompanied by fever, headache, trembling, chills, weakness, and vomiting. Because
there are many causes of diarrhea and dysentery, knowing what treatment to give
depends on the kind of diarrhea.
These signs can help you know which diarrhea disease a person has:
l Cholera: diarrhea like rice water, severe intestinal pain and cramping, vomiting
l Typhoid: fever, severe intestinal pain and cramping, headache, constipation or
diarrhea
l Giardia: diarrhea that appears greasy, floats and smells bad, gas and burps that
smell like rotten eggs
l Dysentery: bloody diarrhea, fever, severe intestinal pain and cramping.
Management for diarrhea at tier 1

l Diarrhea is best treated by giving plenty of liquids and food. In most cases, no
medicine is needed. These diarrhea diseases need special treatment
l Diarrhea is best treated with a rehydration drink/ORS, zinc sulphate, lots of
ﬂuids and easy-to-digest foods to replace nutrients lost through diarrhea. The CHV
should refer all diarrhea cases to the health facility.
Prevention of diarrhea diseases

Because most diarrhea diseases are related to poor sanitation and hygiene,
contaminated water and food, they are best prevented by protecting water sources
and improving sanitation.
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Key points: Prevention of diarrhea diseases

l Do not drink water from unprotected sources
l Make water safe to drink by treating it
l Use toilets and wash hands with soap and running water after use
l Wash hands with soap and water before handling food
l Cook food well and cover to protect it from germs
l Clean baby feeding utensils and eating utensils with soap and
clean running water after use and dry on a dish rack
RActivity 6:
Ask participants to share their experiences of worm infestation in their community and ask the
following questions for brainstorming.
l Who are affected?
l What are the signs of worm infestation?
l What steps do the community take to address the worm problems?
l How can worm infestation be prevented in their community?
As you list down their responses, share information in the following resource notes with the participants.
Ü
Resource Notes on health problems caused by unsafe water
WORM INFESTATION
Some worms and other parasites that live in surface water can get into people’s intestines and
cause diseases. The larger ones can be seen, but most cannot.
Stepping into or washing with contaminated water, drinking this water, or eating uncooked
shellfish or plants can pass these worms and parasites to people.
HOOKWORMS
The hookworm is a parasite that lives in the small intestine of
its host, which may be a mammal such as a dog, cat, or human.
Hookworms are much smaller than the giant roundworm

The most significant risk of hookworm infection is anemia,
secondary to loss of iron (and protein) in the gut. The worms
suck blood voraciously and damage the wall of the stomach.
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Hookworm is a leading cause of maternal and child morbidity in the developing countries.
In susceptible children, hookworms cause intellectual, cognitive and growth retardation,
intrauterine growth retardation, prematurity, and low birth weight among newborns born
to infected mothers.
Signs and Symptoms

There are no specific symptoms or signs of hookworm infection. However, they give rise
to a combination of intestinal inflammation and anaemia. Larval invasion of the skin might
give rise to intense, local itching, usually on the foot or lower leg, which can be followed
by lesions that look like insect bites, can blister (“ground itch”), and last for a week or more.
Prevention
The infective larvae develop and survive in an environment of damp dirt, particularly sandy
and loamy soil. They cannot survive in clay or muck.
The main lines of precaution are those dictated by sanitary science:

l Do not defecate in places other than latrines, toilets etc.
l Do not use human excrement or raw sewage or untreated ‘night soil’ as
manure/fertilizer in agriculture
l Do not walk barefoot in the toilet or in areas with human or animal feaces
l Deworm pet dogs.
ROUNDWORMS
Roundworms are parasites that can infect people. They usually
live in the intestines. There are different kinds of worms that can
cause infection, and they can range in length from 1 millimeter
to 1 meter.
Most often, eggs or larvae live in the soil and get into the body
when you get them on your hands and then touch your mouth.
Some can also get into the body through the skin.
Like other parasitic diseases, roundworm infections happen more often in warm, tropical
climates. Ascariasis is the most common roundworm infection, and affects as many as 1
billion people worldwide.
Signs and Symptoms

The signs and symptoms of roundworm infection include:
Ascariasis
l Cough
l Shortness of breath
l Abdominal pain
l Nausea and diarrhea
l Blood in the stool
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l Weight loss
l Fatigue
l Presence of the worm in vomit or stool.
Risk Factors
The risk factors for roundworm infection include:
l Living in or visiting a warm, tropical climate
l Poor sanitation
l Poor personal hygiene
l Crowded conditions, such as day care or institutional settings
l Weakened immune system
l Malnutrition
l Eating undercooked meat
l Eating dirt or clay -- children tend to become infected this way
l Contact with animal faeces
l Multiple insect bites.
Diagnosis
Diagnosing roundworm infection involves finding out which worm is causing the
infection. If you have lived in or visited an area where these parasites are common, your
doctor may suspect an infection. If a worm passes through the mouth or rectum, take it
to your doctor so it can be identified.
Preventive Care
It is easier to prevent roundworms than to cure them. The steps to preventing roundworm
infection include:
l Practice good personal hygiene. Wash hands and avoid contact with faecal
matter
l Don’t eat uncooked or unwashed fruits and vegetables
l Stay away from mosquito or fly-infested areas; don’t drink unfiltered water,
and don’t touch the soil in areas where roundworm infections are common
l Wear protective clothing, and use insect repellant
l Cook or freeze meat thoroughly
l Keep children away from pet faeces
l Ask a veterinarian about deworming pets
l Public health measures include improving general sanitation, especially
sewage disposal, and reducing mosquito and fly populations.
Treatment
The main treatment for roundworm infections are medications that kill parasites
(deworming).
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GUINEA WORM
Guinea worm is a long, thin worm that lives under the skin and
makes a painful sore on the body. The worm, which looks like a
white thread, can be over a meter long. Guinea worm is found
in parts of Africa, India, and the Middle East.
Signs of Guinea Worm

l A painful swelling develops on the ankle, leg, or
elsewhere on the body
l After a few days to a week a blister forms which soon bursts open and
forms a sore. This often happens when standing in water or bathing. The
end of a white thread-like guinea worm can be seen poking out of the sore.
The worm works its way out of the body over the next week
l If the sore gets dirty and infected or if the worm is broken by trying to pull
it out, the pain and swelling spread and walking becomes impossible
l To treat guinea worms refer to a health facility.
BLOOD FLUKES (Schistosomiasis, Bilharzia)

This infection is caused by a kind of worm that gets into the
bloodstream after washing or swimming in contaminated
water. The illness can cause serious damage to the liver and
kidneys, and may lead to death after months or years.
Sometimes there are no early signs. A common sign in some

areas is blood in the urine or bloody stools. In areas where this
illness is very common, people with only mild signs or belly
pain should be tested.
To prevent Blood Flukes

Blood Flukes do not spread directly from person to person. Part of their life, they must
live inside a certain kind of small water snail. Blood Flukes are preventable if people
follow the most basic preventive step: never urinate or defecate in or near water.
Bilharzia is best treated with medicines; refer to a health facility.
TO PREVENT WORM INFESTATION

l Reduce contact with contaminated water
l Keep animal waste out of water
l Use toilets and wash hands with soap or ash and running water after using
the toilet
l Cook food well and cover it to protect it from germs
l Trim fingernails and wash hands at critical times
l Wear shoes to prevent worms from entering through the feet
l Settle, filter, and treat drinking water
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RActivity 7:
WATER TREATMENT AT HOUSEHOLD LEVEL (40 MIN)
Discussion on Water Treatment at Household
l Ask the participants to raise their hands if they don’t treat water in their household, find out
reasons why they do not treat water in their household.
l Ask the participants to raise their hands if they treat water in their household, and ask them why
they treat water in their household.
l Emphasize on the importance of water treatment at the household level as explained in the
following key points.
Key points: Importance of Water Treatment

at Household Level
Some sources are not as safe as they seem. Just because clear water
flows from pipes, tanks, or wells does not mean it is not contaminated or
does not need treatment
l Rainwater can be contaminated due to dirty roofs or tanks
l Water by vendors can never be trusted as safe
l Piped water may be unsafe due to breakages and illegal tapping
l The safest policy is to treat all drinking water at household level
Ask the participants, “How do you treat water at your home? Why do you use the method to treat
water?”
Copy the table below on a flipchart and complete the table with the responses from the participants.
How do you treat water at your home? Why do you use the method to treat water?
As you list down their responses, check whether the points in the following table are mentioned. if
not, add as you summarize their responses.
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Considerations for Choosing Appropriate Water Treatment Methods in Particular Settings
Water Treatment Advantages Disadvantages

Methods
Boiling water l Some or many families are l Few families already boil drinking
already boiling water. water.
l Fuel is easily available and free or l The fuel used is not easily
affordable. available unless purchased.
l Fuel burns relatively cleanly &/ l Taking fuel is causing

or young children are not greatly deforestation and flooding.
exposed to smoke from fire
l Burning fuel creates lots of
(because well-ventilated, children
smoke that babies are exposed to
kept at distance, etc.).
(indoor burning, babies near fire,
l Mothers have time to boil. poor ventilation).
l Mothers are already too busy to
boil.
l Families don’t take sufficient care
in storing and retrieving their
water.
Chlorination l No commercial product is

l Commercial product available,
available, accessible, and
accessible, and affordable.
affordable.
l Instructions for use are clear and
l Instructions are not clear and
understood.
understood.
l People can understand and
l Bleach or other chlorine products
are motivated to follow simple
are sometimes or often sold
instructions.
diluted or concentration is not
l Residual chlorine protects water consistent.
up to 7 days if covered and up to
l People have trouble following
24 hours if uncovered.
simple instructions.
l Families dislike taste of properly
chlorinated water.
l The water is turbid.
Filtration l Effective filters are available, l Effective filters are not available,
accessible, and affordable. accessible, and affordable.
l Instructions for use are clear and l Instructions for use are not clear
understood. and understood.
l The family has time to use and l Mothers are already too busy to
maintain the filter properly. use and maintain filter.
SODIS l Climate is usually cloudy and

l Climate is mostly sunny. rainy.
l Families either can find or l Many families cannot purchase
purchase safe (PET) plastic safe (PET) plastic bottles, nor can
bottles or program can provide they get them for free.
bottles.
l People have trouble following
l People can understand and simple instructions.
are motivated to follow simple
instructions. l Families need to treat large
volumes of water.
l A cadre of community-based
workers can monitor solar l No cadre of community-based
disinfection. workers can monitor correct solar
disinfection.
7
MODULE
l Discuss with the participants which water treatment methods are most appropriate in their
community according to how much water they need, what it is contaminated with, and what
resources are available
l Discuss with the participants how to promote water treatment at household in their community
refer to module 3 of the guide for training.
RActivity 8:
WATER TREATMENT METHODS (2 HRS)
Demonstration of Water Treatment Methods
To demonstrate using chlorine commercial products we need to do the following:
1. Skip any treatment methods that are not feasible in CHV communities. For example, if no
chlorine products or filters are available, do not teach those methods, unless your program will
make those products available.
2. If a shortage of wood or other fuel for boiling water exists, skip the session on boiling (as
long as other feasible alternatives exist). Consider and discuss the sources of safe and unsafe
water in that community. Talk about issues of smell and purity/ quality of the water.
3. In addition to the products listed above, PUR® may be available. PUR is a complete water treatment
product—it chlorinates as well as acts as a flocculent to clarify turbid water and remove heavy
metals. It requires some investment of time on the part of the user, and the waste collected from
the process must be properly disposed of (in a latrine or other dedicated area), but it is a very
effective method to use, especially in places where turbidity is a significant problem. PUR is quite
expensive relative to a chlorine only product. Some products come in both tablet and liquid form.
The dosing recommendations and instructions are unique to each product. Make note of what is
commonly available and used and be prepared to discuss/demonstrate both types if necessary.
4. Compare how water is currently being treated in the community and the ideal way of doing it.
Generate a discussion around it and understand why this practice is happening and not the ideal
and how best you can address the issues raised around treating the water.
To demonstrate using SODIS (Solar Water Disinfection) products we need the

following items
1. SODIS should be offered as an alternative only if PET plastic bottles are widely available. You can
identify PET bottles because, unlike PVC-type plastic bottles, they burn easily (with a sweet smell).
If PVC bottles are also available, the participants need to understand that they should not be used
7
MODULE
for SODIS. Glass bottles can be used for SODIS, as long as they have a reusable lid. SODIS bags are
available in some communities. Find out whether participants come from communities that have
them. If not, do not discuss, but tell participants that they exist.
2. Using the word “germ” will depend on the audience’s acceptance of the concept. Some CHV
audiences will not understand “germs,” so adjust your vocabulary. Some cultures use the term
“small bugs,” for example.
3. If the sun is not shining, ask participants to tell you what it feels like when they are out in the bright
sun, or what happens when they touch metal that has been in the sun, etc. Reinforce that the sun’s
heat and rays are strong enough to make water safe to drink if the process is done correctly. Do not
use scratched bottles because scratches will block sun rays from penetrating the water.
Water Treatment
Do not drink water from unprotected sources
How do you treat water?
Settling/Decanting Chlorinate
Filtering through cloth Boil SODIS
l For Accidental Chlorine/Water Guard contact with eye/skin, wash

with clean water and soap
l Always Check validity period of Water Guard before use
7
MODULE
Treatment, Safe Storage and Handling of Drinking Water

Ask the participants to state how they currently handle and treat drinking water in their community
and what actions have been put in place by the community for the safe treatment and handling of
drinking water. Compare their answers with the points in the table below.
Current Practice Actions
Some parts of the country have limited l Drinking water source: use water from protected sources
access to water, so they get water from e.g. springs, water pans
water kiosks/vendors who get from
l Treat water before drinking with one of the following
commercial boreholes.
methods:
– Water Guard – Chlorine Tablets (aqua tabs)
Water is not treated before
consumption because: – Boiling – PUR (more expensive)
– Rain and spring water is blessed – SODIS
– Water is clean early in the – Use chlorine pots for hand dug wells
morning
l Use narrow necked containers or pots for storing drinking
– Smell and taste of treated water
water
is not desirable
l Keep water container always covered
– Expensive (boiling)
l Use one cup to draw/collect water to serve and use a
– Can’t access treatment products
separate clean cup for drinking
– No knowledge of treatment
l Use jerrycan with tap or improvise by purchasing a tap and
options
fit it on it
– Borehole considered safe
l Pour water from jerrycan or clay pot directly to clean cup or
– Piped water considered safe jug
– Bought water supposed to be l Store water in covered jug or 5 litre jerrycan for children to
safe. use
l People store water in jerrycans or l Construct a ladle with a long handle for drawing/retrieving
clay pots (agulu or da‐pii) that are water. Hang the ladle on the wall or place on top of water
usually covered. container OR
l Tie cup with string to container or put on reed (fito)
hanging in house
l Teach children to use the cup/ladle (kata)/fito system
l Keep water container away from animals.
l People use 100 gallon drums to Dedicate smaller (10 or 20 litre) covered, narrow‐neck
store water then they dip containers container to drinking water to allow treatment of only
into the drum for different uses drinking water.
l People consider treating drinking If water is turbid:

water a burden when they have to l Add ash/alum to water to help clear turbid water
fill a 20 litre jerrycan and then treat
it l Use 3 pot system to clear water or let water stand overnight
and pour in another container (straining system)
l Cups are often used to dip into
water when it is served l Then treat water as above. Have separate water pans for
animal and human consumption
l People clean water containers with
soap in the urban areas or with l Carry treated drinking water from your home to wherever
leaves and sand/ash in the rural you go.
areas
l People drink unsafe water outside
the home e.g. in school, market
places, church
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MODULE
RActivity 9:
SAFE WATER STORAGE (30 MIN)
Group Work on Important Tips on Safe Water Storage
l Ask participants, “What do we have to do with the treated water?

l Divide the participants in groups and ask them to write down important tips to prevent treated
water from becoming contaminated during storage on flip chart. Give them 10 minutes for the
activity
l Allow 2 or 3 groups to present or use gallery notes and the others to make inputs
l Compare with the key points below and let the participants discuss how to improve the water
storage at household in their community.
Key Points: Water Storage

To prevent water from becoming contaminated during storage:
l Pour water out without touching the mouth of the container,

or use a clean, long-handled dipper to take water out of the
container. Do not let the dipper touch anything else, or it will
contaminate the clean water when it is used again
l Empty and clean the container with hot water every 2 or 3

weeks
l Keep containers covered
l Keep drinking cups clean
l Never store water in containers that have been used for

pesticides or toxic chemicals
l Do not treat more water than you need for short-term use,
if possible. For drinking and preparing food, that is usually
about 5 litres for each person each day
l Wash hand with soap before treating and pouring water
7
MODULE
UNIT 2
SANITATION
7
MODULE
7
MODULE
Unit 2
SANITATION
l Understand what sanitation is
l Understand various components of sanitation
l Understand health problems caused by poor sanitation
l Understand factors hindering personal and environmental sanitation.
Methodologies: Brainstorming, discussion, community-mapping, field trips, demonstration

and role-play.
Materials: Newsprint, Felt/Marker pens, Masking tape, Newspaper cuttings, Pens,

Note books.
Unit Session Plan

20 min Purpose of this unit Role play

and Objectives of this unit
20 min Definition of Sanitation Brainstorming/

Discussion
4hr 5min Components of Sanitation Discussion and

and Sanitation Ladders Demonstration
2 hrs Health Problems caused by Poor Sanitation Discussion,

Group Work
1hr 30min Factors Hindering Environmental Sanitation Group Work,

Discussion and
Lecture
7
MODULE
UNIT 2 : SANITATION
RActivity 1:
PURPOSE AND OBJECTIVES OF THIS UNIT (20 MIN)
Story to Learn the Purpose and Objectives of this Unit
Ask two volunteers to role play the following story.
Two people walking

4
Two people were seen walking from a nearby market going to their
homes. Along the way one person says that he/she would like to
relieve him/herself and walks to a nearby bush, which is just above
the community water spring.
Ask the participants the following questions:

l What did you see?
l What did you hear?
l Does it happen in our communities?
l Why does it happen in our community?
l When does it happen?
l What can we do about it?
RActivity 2:
DEFINITION OF SANITATION (20 MIN)
Ask participants what they understand by environmental sanitation.
them or not and if not, add as summarizing their responses.
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MODULE
UNIT 2 : SANITATION
Key points: Definition of Sanitation

It is a practice or behavior of keeping our surrounding clean and
free from disease causing germs. It includes:
l Solid waste management
l Waste water management
l Insect vector control e.g. jiggers, mosquitoes cockroaches
l Human waste management
COMPONENTS OF SANITATION AND THE SANITATION LADDER

(4 HRS 5 MIN)
Components of Sanitation
RActivity 3:
Place the participants into three groups;
Group 1:
To list and explain the waste disposal methods at household level.
Group 2:
To list and explain waste water disposal methods at household level.
Group 3:
To list and explain insect vectors control methods at household level.
Ask each group to present their findings after which you summarize with the following key points.
7
MODULE
UNIT 2 : SANITATION
Key points: Components of Sanitation

The components of sanitation are grouped into four categories
as follows:
1. Solid waste management under which we have:

a) Household wastes which can be managed by;
– Burning wastes such as papers and litter
– Burying the wastes that cannot burn
– Composting the waste that are easy to rot and
be used as manure.
– Reuse of some wastes e.g. plastic bags, papers,
metals etc.
2. Waste water management which is achieved through:

a) Discharging into kitchen garden
b) Discharging into a soak pit
c) Discharging into communal drains incase of towns
3. Insect vector control (cockroaches, bedbugs, jiggers,

mosquitoes) this can be controlled by good housing and
clean environment.
4. Human waste is disposed by use of a pit latrine and other

ways:
a. Pit latrine
b. VIP latrine
c. Water closet
RActivity 4:
Ask participants what they understand by faeces disposal.
them or not and if not, add as summarizing their responses.
7
MODULE
UNIT 2 : SANITATION
Key points : Faeces Disposal

Faeces disposal practices include:
l Defecate in a small hole, then cover with earth (Cat’s method)
l A traditional pit latrine or basic ecosan solution
l An improved pit latrine with an improved slab or ecosan solution
l An improved pit latrine with ventilation
l Flush toilet with on-site disposal
l Flush toilet with sewage and waste water treatment
Two faeces disposal methods create a large risk of spreading diarrhoeal disease. These are never
acceptable practices:
l Defecation in the compound by young children
l Defecation in the open—indiscriminately.
RActivity 5:
How faeces can be spread (30 min)
Introduction (5 min)
Tell participants that during this session they are going to learn about how faeces can be spread, how
they can be dangerous, and something about how people in the community dispose of their faeces.
They will also learn about the sanitation ladder concept.
Climate Setter (5 min)

1. Ask participants to name some common defecation practices in the community (use the culturally
appropriate word) and how people presently dispose of their faeces.
2. Record answers on a piece of flipchart paper. Ask their opinions about each answer. Do not belabor
this discussion:
l What do you think about this practice?
l What are positive and negative aspects to the current practices?
7
MODULE
UNIT 2 : SANITATION
Large Group Discussion and Task (20 min)

1. Hold up the picture of the person openly defecating and ask participants:
l What happens when someone defecates in the open?
2. Take a few answers. Then ask:

l Where do the faeces go?
l What happens to them when it rains?
l How do people feel about stepping in faeces?
l Does the smell of faeces in the community bother people?
l What do people think about someone who defecates in open areas?
Complement the discussion by emphasizing that all faeces is potentially dangerous and needs to be
“treated with care” because all faeces contain germs that can cause illnesses in people. This is why
faeces should be deposited in a latrine or toilet where they cannot be transported by one of several
possible routes—water, dirt, food, flies, or hands—into the mouths of other people. When someone
sick defecates in the open, s/he is putting everyone at risk of catching the same illness.
3. Ask each table to write three or four actions that the community could take to help stop the spread
of faeces.
4. When the tables are done, collect suggestions from around the room. Record answers on a
flipchart. Open the discussion and let people add suggestions.
RActivity 6:
The Sanitation Ladder (1hr 50 min)
Tell participants that during this session they are going to learn more about the sanitation ladder,
look at actual community practices, and talk about ways to get the community members to properly
dispose of (isolate) their faeces. In addition, they will review hand washing and cleaning practices with
special attention to its importance after defecation.

1. Quickly review the different steps on the sanitation ladder and ask where the participants think
most community members are at the present time regarding faeces disposal.
Extend the conversation to talk about the faeces of babies, sick people, and animals and why it’s
important to think about the correct disposal of these kinds of waste. Record answers on flipchart.
2. Ask participants what they think about these practices. Do not belabour this discussion or record
the opinions.
7
MODULE
UNIT 2 : SANITATION
On the ladder (in order from least acceptable [#1] to “best” practice [#8]):
The steps on the sanitation ladder
1. Defecation in the open—indiscriminately (includes children defecating in compound).
2. A designated place in the open for defecation (not an acceptable option unless in an
emergency setting).
3. Cat’s method (in a small hole and covered with earth).
4. A traditional pit latrine or basic ecosan solution (this option meets the Millennium
Development Goal criteria for faeces disposal).
5. An improved pit latrine (generally means improved slab) or ecosan solution.
6. An improved pit latrine with ventilation.
7. Flush toilet with onsite disposal.
8. Flush toilet with sewage and waste water treatment.
Table Discussion (30 min)

1. Referring to the sanitation ladder list on the wall or the copies on the desk, ask the participants
at each table to talk about the pros and the cons of a few methods of disposing of excreta and to
record those on flipchart paper. (The number of methods per table will vary depending on the
number of tables.)
2. When the tables have completed and posted their work, ask participants what they’ve begun to
conclude about the steps on the ladder. Briefly discuss the pros and cons of the different methods.
3. Open the discussion by asking the participants how they might get community members to “move
up the ladder”.
Encourage creative ideas.
Role Play and Discussion (30 min)

1. Pass around Assessment Cards and have two participants assume the roles of CHV and household
member. Have the CHV assess where on the ladder the family is and practice negotiating how they
could move up the ladder.
2. Ask participants to recall the most important things to remember when it comes to handling
faeces (proper disposal of faeces and hand washing). Record answers.
3. Remind participants about how to wash their hands (based on what they remember from the
hand washing sessions). Talk about “washing” with soap or ash, air drying, how long to wash, etc.
7
MODULE
UNIT 2 : SANITATION
The sanitation ladder idea is useful to help CHVs assess current faeces disposal practices and give them
options for working with families to promote improved practices. The ladder indicates, from most
dangerous to safest, the options for how people dispose of faeces. Using the ladder concept can help
a family take small, incremental steps up the ladder. Adapt the ladder to use the different steps from
your community.
Contest: Creating Sanitation Ladders (30 min)

1. Provide pre-written pieces of paper with different forms of faeces disposal methods to the
participants, each getting a piece of paper. Pin one of the prepared cards on the back of each
participant.
2. Let the participants move around the room to find out what other members have as a method of
faeces disposal.
3. In the process encourage participants to form a sanitation ladder according to the available
members in the room, having the lowest level of the ladder as the head of the queue that the
participants have formed.
4. The trainer will facilitate the discussion of the sanitation ladder as the participants stand in a queue,
for them to explain how they made up their ladder and why.
5. Depending on the number of participants, there will be 3-6 sanitation ladders. Once people have
formed a line, have the groups decide which is the most complete.
Review and Draw Conclusions (5 min)

1. Ask participants talk to another person about how they could use this information in their work as
a CHV:
l What did you learn during this session?
l Are you comfortable enough with the subject matter to facilitate a session with an
individual, family, or group?
l What will you remember about faecal-oral transmission when you are working with
community members?
l What else do you need to know/to do to be ready?
2. Summary points:
l Review current practices in the community
l List some serious diseases spread by not isolating faeces
l What are the potential perceptions of open defecation in the community?
l What are some potential dangers of open defecation?
l Review the steps on the sanitation ladder.
7
MODULE
UNIT 2 : SANITATION
RActivity 7:
Latrine Basics (1 hr 45 min)
Tell participants they will talk about some latrine basics, some maintenance guidelines, and suggestions
for correctly using latrines.

1. Ask participants what they know about the current situation in the community regarding presence
and use of latrines.
2. Find out why latrines are built and not used, for example. Or why people are reluctant culturally to
build latrines, etc. What do participants think motivates families to build latrines?
Discussion Task (two discussion groups) (20 min)

1. Ask participants on one side of the room to think about what would be a good set of guiding
principles for building a latrine.
2. Ask the participants on the other side of the room to discuss at least five ways to keep latrines
clean.
3. Give them time to talk and then take some answers. For the guiding principles, make sure they
include:
l Adequate pit depth to last a family at least two years—ask about local practice
l Placement at the back of the house within 30 meters and at least 30 meters (downhill)
from a water source
l Pit should not go into ground water—especially if people in the village get water from
wells
l Hole must have a cover to discourage flies
l Privacy and comfort.
For keeping latrines clean, make sure they include:

l Check the structure daily to make sure it’s firm and verify the platform is firm
l Keep latrine covered
l Wash down or sweep into the hole any faecal material that’s on the slab
l Verify that the platform is solid
7
MODULE
UNIT 2 : SANITATION
l Keep animals out of the latrine and don’t allow insects to live in the latrine
l Clean the slab daily with quicklime or ashes by sprinkling a handful or two on the slab to
soak up moisture around the hole and then sweep into the pit
l Clean concrete slabs with water and bleach or soap.
Trios: Discussion in Groups (30 min)

1. Count off by threes. Ask each group to come up with some reasons why latrines are not used, or
used improperly.
2. When each group has worked for a few minutes, write some responses on cards or a flipchart.
3. In the large group, for each reason that a latrine is not used, have participants come up with a
solution. (For example, for the reason “It’s too smelly,” a counter argument might be that “It’s easy
to install proper ventilation, keep the latrine clean, or cover the hole.”)
4. Discuss some points about the protocol of latrine use. This might include: putting a tippy tap near
so people can wash their hands immediately upon exiting the latrine, keeping a supply of wiping
material handy inside the latrine, respecting people’s privacy, etc.
Synthesis on Faeces Management and Latrines (45 min)

1. Ask participants to think about the following questions and to construct a chart to help them start
work in the community. Use the table found at the end of this session to facilitate this conversation.
2. What are the most pressing problems in the community regarding the effective disposal/ isolation
of faeces?
l Who are the potential audiences for targeting your activities?
l What are the most prevalent behaviors related to faeces disposal?
l What are things that make it difficult to improve practices?
l What are things that make it easier to improve practices?
l What are some motivational activities from the water, hand washing, and faeces sessions
that might be done in the community?
7
MODULE
UNIT 2 : SANITATION
Major issues in the Community One Community Two Community Three

community
about disposal
(isolation) of faeces
Possible audiences
for mutual
Planning or group
activities
Behaviors now
prevalent
Alternatives to
current behaviors
Barriers to adopting
new practices
Enablers to adopting
new practices
Potential activities
for CHVs
Discuss as needed. Post the charts on the wall for a gallery walk, if time permits.
Ask the participants:
l What are the main barriers to safe disposal of faeces in the community?
l What can a CHV do to address the problems?
List down their responses and share information that appears in the following table on
‘Barriers to Safe Disposal of Faeces’ with the participants.
7
MODULE
UNIT 2 : SANITATION
Barriers to Safe Disposal of Faeces
Common reasons why people don’t What an outreach worker can do to address this barrier
dispose of faeces safely (barriers)
People don’t know how important the Explain and show the community the most likely ways that
disposing of faeces properly is. They don’t germs can go from faeces into people to make them sick. To
connect where they defecate with their explain the effects of diarrhea, mention what happens to crops
children getting sick, and/or they consider when they don’t get enough water. Acknowledge that it should
diarrhea a “normal” and not dangerous not be common for children to get diarrhea and that one of the
condition. key ways to reduce it is for everyone to dispose of their faeces
safely.
People accept open defecation as normal or CHVs can work with the families using some of these training
traditional. exercises, sharing about how faeces on the ground eventually
cause illness. In some settings, creating a sense of disgust or
even shame (using CLTS) has worked.
Families don’t have latrines. Some, especially CHVs cannot address all these problems alone. They must have
in urban slums, may not have space far strong support from the government or an organization. NGOs
enough from the house. Some may live on should do a technical assessment to decide the best latrine
land where only a hole lined with rock or options for the conditions and should link program participants
cement would work. Some don’t understand with loans, materials, or skilled labor.
the importance or otherwise are not
sufficiently motivated. Some don’t know how
to build one. They may lack tools and basic
materials. Some cannot afford the materials
and/or labour necessary to construct a
latrine.
Latrine is not situated within 10m from the Advise a new location if a better one is available; explore access
home and at least 15m downhill from a water to a public or neighbor’s latrine if building one is not possible.
source.
People don’t use the latrine at night because Suggest using candles or flashlights, but also explore using a
it’s too dark, there are too many bugs potty, with ash in the bottom (and put additional ash on top
and vermin, and especially for women it’s of faeces), that can be emptied in the latrine or hole in the
dangerous to walk alone at night. morning.
Latrine is not well-cleaned, so faeces or urine Try to problem-solve with the family how it can be kept clean
stains are on the floor and seat. and advocate that family members share responsibilities; it
shouldn’t just be added to the mother’s burdens. If multiple
families share the latrine, discuss how to improve maintenance.
Latrine is used for storage or other purposes. Motivate owners to use the latrine as intended; suggest other
possibilities for storage.
Latrine is not well-used because it stinks. Consult with the local environmental health officer. Use
quicklime or ash to clean the slab daily. Sprinkle a handful or
two of ash on the slab to soak up any moisture around the hole
and then sweep it into the pit. Add small, high windows for
ventilation in the structure. Covering the hole helps to reduce
smell.
Latrine is not well-used because it is infested Consult with the local environmental health officer.
with worms or bugs.
Latrine hole is filling up with water. Move the latrine location if possible. This will solve the problem.
Or build a rock-lined or cement-walled hole, if feasible.
Latrine is not well-used because there is no Buy toilet paper or have children collect paper trash or leaves
wiping material. for wiping. Once used, it can be burned or put in the pit. In
places where people use water to clean, problem-solve to make
enough water available.
Family cannot/will not build latrine because Encourage community to facilitate the shared use of
it has no tools to dig hole. appropriate digging tools.
In some cultures, it is not acceptable for men A family could either build a second latrine, or could negotiate
and women or for women and in-laws to with a neighbor so that one family’s latrine could be designated
share the same latrine. for women and one for men.
Children up to age 6 or 8 do not use the Explain that children’s faeces have even more germs than
latrine because they are afraid of falling in adult faeces, so they must defecate either in a potty (with ash
the hole, and they are allowed to defecate if possible) or a latrine. Keep a sanded board in the latrine to
anywhere. cover part of the hole when a child uses it.
7
MODULE
UNIT 2 : SANITATION
Review and Summary

Discuss why it is important not to dispose other waste in the pit latrine. Make the link to the next
session on disposing of faeces for people who are bedridden.
RActivity 8:
HEALTH PROBLEMS CAUSED BY POOR SANITATION (2 HRS)
Discuss health problems caused by poor sanitation
l Put the participants in groups and ask them to discuss and list down health problems caused by
poor sanitation.
l Let three groups present their findings. As you list down their responses, check whether the key
points in the following box are mentioned by them or not and if not, add as summarizing their
responses.
Key points : Poor Sanitation

Health problems caused by poor sanitation include:
l Diarrhea diseases e.g. cholera,typhoid,dysentery

l Water and land contamination
l Breeding of insect and other vectors
l Worm infestations
l Dirty environment
l Risk of fire outbreak
l Foul smells
l Accidents
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MODULE
UNIT 2 : SANITATION
RActivity 9:
ENVIRONMENTAL SANITATION (1 HR 30 MIN)
Factors Hindering Environmental Sanitation
1. Place the participants in groups of four and then let them discuss factors hindering environmental
sanitation and put their findings on the flipchart for presentation.
2. Let three groups present their findings. As you list down their responses, check whether the key
points in the following box are mentioned by them or not and if not, add as summarizing their
responses.
Key points : Environmental Sanitation

Factors Hindering Improvements in Environmental Sanitation
l Lack of adequate and safe water
l Lack of awareness
l Negative cultural beliefs e.g. inability to share toilet
l Negative attitudes
l Poverty
l Illiteracy
7
MODULE
UNIT 3
HYGIENE
7
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7
MODULE
Unit 3
HYGIENE
l Define hygiene
l Describe the types of hygiene
l Understand factors that promote personal and environmental hygiene
l Demonstrate and understand good hygiene practices.
Methodologies: Brainstorming, discussion and demonstration.
Materials: Newsprint, Felt/Marker pens, Pens, Notebooks,

Training/Demonstration materials: Soap and water.
Unit Session Plan

20 min Purpose of this unit Story and

and Objectives of this unit Discussion
10 min Definition of Hygiene Brainstorming
1 hr Types of Hygiene Discussion and

Group Work
3hrs 10 min Hand Washing Demonstration,

Lecture, Group
Work and Discussion
2 hrs Personal, Home and Food Hygiene Discussion

and their determinants and Mini Lecture
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MODULE
UNIT 3 : HYGIENE
RActivity 1:
PURPOSE AND OBJECTIVES OF THIS UNIT (20 MIN)
Story to Learn the Purpose and Objectives of this Unit

Read the following story of Mr. Aseka.
Khwisero village story

4
In Khwisero village community members are gathered for a party to
celebrate good performance of their school. After the speeches, they move
to the dining hall to be served food. One of them, a Mr. Aseka excuses himself
to visit the toilet. On coming back, he goes straight to the table and starts
eating. After eating, Mr. Aseka goes to wash his hands.
l Ask participants what hygiene practices were seen in Aseka’s act

l Ask the participants whether similar practices are seen in the community
l Summarize the discussion and tell the participants – “we are going to learn more about good
hygiene practices”
l Share the objectives for the unit.
RActivity 2:
DEFINITION OF HYGIENE (10 MIN)
l Ask the participants what they understand by the word hygiene?
l Let them brainstorm as you list down their answers
l Summarize to fit the below definition.
Key points : Definition of Hygiene

Hygiene is the practice of keeping oneself and the surrounding
environment clean.
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UNIT 3 : HYGIENE
RActivity 3:
TYPES OF HYGIENE (1 HR)
Discuss the Types of Hygiene (15 min)

Place the participants into groups and ask them to brainstorm and come up with hygiene practices.
l Place the participants in groups and ask them to discuss and come up with various types of
hygiene.
l Randomly let them present their findings.
The facilitator to summarize their findings in relation to the following key points:
Key points : Hygiene Practices

Hygiene Practices involve the following types of food and personal hygiene.
Personal hygiene involves the following:

Bathe regularly, brush your teeth twice a day–especially before going to
sleep and after breakfast, wash hair and keep it clean to avoid lice, wash
eyes and face daily to avoid trachoma.
Put on clean shoes, wash your feet before going to bed to avoid jiggers,
hookworms and bilharzia, wear clean clothes, keep nails clean and short
(refer to school health hygiene).
Examples of Unhygienic Practices to Avoid

l Spitting in the open
l Open coughing
l Blowing of the nose with bear hands
l Sneezing without covering both nose and mouth.
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UNIT 3 : HYGIENE
RActivity 4:
Menstrual Management (45 min)
What to do:
1. Divide participants into focus groups.
2. Ask them to brainstorm and come up with a list of how women take care of themselves during
menstruation.
3. Let them present their group works in plenary.
4. Facilitate a discussion on the issues raised above.
The facilitator to summarize their findings in relation to the following points:
Menstrual Management
Current Practice Small Doable Actions
l Make sanitary pads from locally
l Women and girls do not have
available materials such as
access to appropriate materials
sanitary pads with a plastic sheet
to absorb the blood.
underneath to prevent leakage.
l Some women use linen/cotton
l Install hand washing station in
to make pads, but do not
changing areas/latrines.
properly wash them for re‐use.
l Wash hands with soap and running
l Some households use jik or salt
water after handling blood-stained
to clean materials.
materials or caring for patients.
l The recycled sanitary towels

l Wear gloves or plastic bags when
are not put in sun but hidden
caring for sick person with menses.
under bed.
l For reusable materials soak in soap
l Women/girls do not wash their and water for 20 minutes then
hands after changing their wash with soap and water and dry
soiled menstrual materials. in sun.
l Women and girls do not dispose l Dispose of pads in pit latrines.

of used menstrual materials
safely. l Dispose off the sanitary bin in the
set up
l Caregivers touch menstrual
– Put in waste pit for burning
blood without any kind of
(but dispel cultural taboos
protection on their hands.
about burning blood)
– Dig a deep pit and bury
bloody materials every day.
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UNIT 3 : HYGIENE
Key points : Menstruation

Menstruation is a natural process. However, if not properly managed it
can result in health problems.
Reports have suggested links between poor menstrual hygiene and

UTIs, STIs and other illnesses. The impact of poor menstrual hygiene on
the psychosocial wellbeing of women and girls (e.g. stress levels, fear,
embarrassment, and social exclusion during menstruation) should also
be considered.
HANDWASHING (3 HRS 10 MIN)
How to wash hands properly
RActivity 5:
Tell participants that during this session they are going to learn about how dirty hands can transmit
germs and how to wash their hands properly.

1. Walk around the room with the two drawings (dirty/“clean” hands).
2. Ask for some volunteers to answer questions (examples below) by pointing.
l Which person would you like to prepare your meals?
l Which person would you like to weed your garden?
l Which person would you like to hand you the medicines or tablets when you’re sick?
l Which person would you like to change your bicycle tire?
3. Say that for many activities, we like people with clean hands. For some activities, it doesn’t matter.
Stress that hands can look “clean” and still be dirty. Recall the session on “clear” but “not safe
drinking” water when the water was clear, but in fact was contaminated by faeces. Hands can also
look clean but may not be, so it is important to wash them properly. This session discusses how to
wash hands correctly.
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UNIT 3 : HYGIENE
Demonstrate a Perfect Hand Wash (10 min)

1. Invite one volunteer to participate in an exercise without saying what that exercise will be.
2. Ask the volunteer wash his/her hands as s/he would normally. Ask the participants to be sure to
watch everything that the volunteer does.
3. Ask participants to critique the hand washing effort.
4. Have a discussion about what a person could do differently from what the volunteer did while
washing: “Which steps might be missing?” “What would you do differently?”
5. Generate a list of steps for hand washing. Make sure that these are the same as on the job aid.
6. Are there any risks of washing hands in the same container? No. Discuss. What precautionary
measures need to be considered?
Show the “How Do We Wash Our Hands?” poster. Review the steps on the poster. Compare the
poster with the list of steps generated by the volunteer and the participants.
7. Explain that treated (chlorinated, boiled, SODIS, filtered) water isn’t necessary to wash hands.
However, they MUST use soap or an abrasive such as sand or ash. Say it’s best to rinse under flowing
water and let the hands air dry. Some recommendations include drying hands on a clean cloth or
towel, although a clean cloth or towel is unlikely to be available in many settings. Air drying is the
best alternative in most situations. Remind participants that sometimes in schools they use treated
water for washing hands so students are not exposed to untreated water that could be used for
drinking.
8. If soap is not available or affordable, people can use ash on the job and sand, or even mud as an
alternative to soap, as long as they wash and rinse (with running water) thoroughly. The sand or
ash act as an abrasive and “rub off ” the dirt and germs. The flowing water takes the dirt and germs
away. You can have flowing water by using a tap, a jug, or a tippy tap. Using a basin filled with
water to rinse hands will not make the hands clean because the dirt and germs may not flow off
the hands.
Demonstration Two (5 min)

1. Invite another volunteer to the front of the room without explaining what you’re going to do.
Stand next to the volunteer so that everyone can see you and the volunteer.
Simulate a violent coughing fit, covering your mouth with your hand. Then offer that same hand to
the person for a handshake.
2. Ask the participants what they just saw. Ask what did they think might happen when you shake the
volunteer’s hand. Listen carefully to the answers. List key points.
3. Lead a discussion with the large group about how our hands are always dirty with germs even if
we can’t see the germs. Make the connection about how we transmit germs from one person to
another with our hands.
Ask the participants to tell you what other tasks they do that can get their hands dirty.
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UNIT 3 : HYGIENE
Share information in the following resource notes with the participants.
Ü
Resource Notes on Hand Washing
Hand washing is the single most important thing that you can do to help prevent the spread
of infections and to stay healthy and well. Washing hands with soap and water is a very
effective way of reducing germs on our hands.
l Use running water to wash your hands

l Use soap: bar or liquid, plain or antiseptic (bar soap must be allowed to drain between
uses; use soap racks)
l Use friction, remove dirt from under fingernails
l Timing (10 -15 seconds) is the standard acceptable length of time for hand washing
l Use clean towels (disposable or individual) for drying, or allow to air dry.
How to thoroughly wash your hands using soap and water
Wet hands with water Apply soap to cover all Rub hands palm Rub each palm over the Rub palm to palm with
surface of the hands to palm back of the other hand fingers interfaced
Rub backs of fingers to Rub each thumb Clasp fingers and Rub each wrist with Rinse hands with
opposing palms with clasped in opposing circular rub opposing opposite hand clean running water
fingers interlocked palm palm and air dry
Review and Summary (10 min)

1. Ask participants the following questions.
Who should wash their hands?

Everyone should wash their hands: adults, the elderly, young people, children, and babies. If children
are unable to wash hands by themselves, an adult should help them.
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UNIT 3 : HYGIENE
How should we wash our hands?

We should wash our hands with water and soap. To wash our hands correctly, we wet them, soap them,
rub them together at least three times, clean under our nails, between fingers, and up to our wrists,
and rinse them with running water. We air dry them by shaking them or we use a clean towel (only if a
clean one is available).
If I don’t have soap, what can I use as a substitute?

Soap is the best cleanser to use, but if no soap is available or affordable, you can use ash or sand as an
alternative to soap because all of these are abrasive so they help loosen (or “rub off ”) the germs or dirt.
You should then rinse under.
Is “clean” water, i.e., pure or treated water, necessary for washing my hands?
No, washing your hands with any running water even if it has colour makes them cleaner if you also use
a cleaning agent such as soap, sand, or ash. It is better to rinse your hands with running water.
2. Ask participants to talk to the person next to him or her. Have participants call out some answers
and record them on a flipchart:
l What did they learn?
l Do they think the demonstrations will work with their households? Why or why not?
3. Review summary points:

l Sometimes hands get dirty
l Sometimes hands don’t look dirty but can still transmit germs
l The steps for proper hand washing are _________________________________________
a stream of water (fill in from the two lists)
l Ash, sand, and mud are possible substitutes for soap
l Washing hand in a basin filled with water is not acceptable. Flowing water must be poured
over hands to wash off the dirt and germs
l When water is scarce, we ____________________________________________________
(fill in from the discussion).
Make the link to the next session. Now that they know how to wash their hands, it’s important to know
when to wash their hands (at what moments).
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MODULE
UNIT 3 : HYGIENE
RActivity 6:
Critical times for hand washing
1. Tell participants they are going to learn about critical times for washing their hands. They should
be able to identify at least five times when they should wash their hands.
Conclude that there are “before” times (washing hands before something) and “after” times
(washing hands after something). Do not reveal the five times, which are: before preparing food,
before eating food or feeding someone, after using the toilet, after cleaning someone’s bottom
and before and after caring for someone who is sick.
2. Continue by saying that at the end of the session, they will have a chance to examine some
conditions and practices regarding hand washing in their own communities and how they might
help people improve their hand washing practices.

1. Ask the participants when they presently wash their hands with soap or another cleansing agent
such as ash.
2. Then ask what they’ve noticed about hand washing in their community to get some more details
e.g. How many times a day do they wash their own hands? Do they help their children wash? Do
many people wash with water only? What products do they use? How much does soap cost? Etc.
3. Record their answers as they call them out on a piece of flipchart paper.
Table Task (10 min)

1. Distribute the sets of pictures (or words) as appears in the following page—one set per table. Add
extra images of human activity as needed.
2. Tell participants to sort all the images/pictures into two groups: in one group put pictures of
people doing things that require them to wash hands before they do them (like preparing meals);
in the other group put pictures of people doing things that require them to wash their hands after
they do them (like changing the baby).
3. Give them a couple of minutes to sort the pictures. Walk around as they work. If the participants
say “it doesn’t matter,” tell them to establish a third category of pictures.
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Examples of ‘Before’ and ‘After’ Pictures for Activity 6
Before feeding children Before eating
After changing diapers and napkins
After visiting the latrine
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UNIT 3 : HYGIENE
Large Group Discussion (10 min)

Have groups report the results of their sorting exercise. Let the reports be the basis for some discussion.
Some possible questions to get started:
l How many “before” pictures do you have?
l How many “after” pictures do you have?
l How many pictures did your group put into the “didn’t matter” group?
l What did your group notice about the pictures?
l Can your group estimate how many times someone would wash his or her hands if that
person washed when recommended?
l What do you think are the most critical times for washing hands?
Table task (10 min)

After each table has reported, have the participants go back and add anything they feel should be part
of the two lists (e.g. before praying). They can write these on paper.

1. Ask the participants to review the poster about the times when hands should be washed.
2. Have participants discuss with their neighbors how they might talk about this topic with families
in their communities:
l What did they learn about when to wash their hands?
l Do they think they can use the pictures to illustrate when the best times are to wash hands?
l Would the sorting exercise work in their community?
3. Review summary points from this session:

l Wash your hands before ________________________________________________ (fill in).
l Wash your hands after _________________________________________________ (fill in).
l Always wash your hands with soap or ashes or sand, because water alone will not get them
clean enough, and rinse them using running/pouring water.
Tell participants the next session takes a look at how much water is necessary for proper hand washing.
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MODULE
UNIT 3 : HYGIENE
RActivity 7:
Overcoming barriers to proper hand washing
1. Explain that participants will learn about overcoming barriers to proper hand washing. Hand
washing should be made as easy as possible by keeping water and the cleansing agent in several
places: beside the latrine, outside the kitchen or eating area, and next to a bedridden person’s
bed. When hand washing stations with water and soap are not convenient, it is much less likely
that people will wash their hands well and when needed. Another reason that people do not wash
their hands is that it requires a quite a lot of water, which can be difficult for households that have
limited access to water or have to pay for water.
2. Say that we will start by talking about how much water is needed to wash hands properly.
1. Ask participants to guess how much water it takes to effectively wash hands that:
l Are very dirty from working in the fields
l Look clean but just changed the baby’s dirty diaper.
2. Record participant answers on the flipchart.
Large Group Demonstration and Table Task (30 min)

1. Ask for one volunteer to demonstrate correct hand washing for all the participants. Ensure
someone assists him or her so the water can flow to rinse hands. Ask observers to remember the
steps learned in the last session on the proper ways to wash your hands and have them coach the
hand washing volunteer on correct technique.
Catch all the waste water in a basin/bucket.
2. Fill a cup with wastewater from the basin and pour it into an empty bottle/basin. Continue until
the waste water is gone, having the participants count the number of cups that it took. Have the
group take notice of how full the bottle/basin is (mostly full, overflowing, half full, etc.) and display
it somewhere in view. Explain that they are going to use this measurement in the next exercise.
3. Next, explain that participants will look at how many times a day a typical family needs to wash
their hands and how much water that household would need. Ask participants to think about
a family of six and figure roughly how many times a day this means they will wash their hands.
Let’s assume that this family of six has an infant, one toddler less than two years of age, two older
children, one man who is ill and bed ridden and takes medication three times per day, and one
woman who currently has her menstrual period.
4. Walk the participants through the following table (posted on the wall or a flipchart), briefly explain
the numbers and the math, but do not dwell on it.
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UNIT 3 : HYGIENE
Water Calculation Table

Example for family of six (including one infant, one toddler, two older children, one man who takes
medication three times per day and is bedridden, and one woman who currently has her menses).
Example Column “A” Number Column “B” Number Total number of
of times a day/ each of family members times a day (Multiply
person doing this Column A x Column B)
After defecation 2 4 (woman, man, 2 older 8
children) (2 babies don’t
wash THEIR hands)
After changing a nappy/
diaper and cleaning a
baby’s bottom 6 2 12
After changing material 4 1 4
used to absorb (menstrual period)
menstrual blood
Before preparing 3 2
food/Cooking (mother and daughter) 6
Before taking/giving 3 1
Medication (father) 3
Before eating 3 4 12
Before feeding 3 1 3
(toddler that is
eating solids)
Before breastfeeding 6 1 6
(baby that is still
breastfeeding)
TOTAL 54 TIMES A DAY
5. Explain that now they have an estimate that this family of six needs to be washing their hands 54
times per day.
6. Tell participants that they will now multiply the number of washes a family must do per day (e.g. 54
hand washings per day in the example above) by the amount of water it takes to wash your hands.
Locate this bottle/basin filled with water used in just ONE hand washing and ask the participants
to imagine 54 of those bottles/basins. THIS is the amount of water it would take our example
family to wash their hands each day in an ideal fashion.
7. Acknowledge to participants that it takes a lot of water for a family of six to wash their hands
properly! Lead a discussion with the group, asking participants about the following key points:
l What kind of container is used in the communities to transport water?
l How far do people in the community have to go to get their water?
l How many extra trips to the water source (e.g. well, tap, etc.) would be required each day to
follow the ideal recommendation of hand washing at the critical times?
l Who actually transports the water (young girls, the woman of the household?) What would
this extra burden mean for them?
8. Now ask participants if these kinds of issues will affect whether someone will or will not wash their
hands at critical times. Spend two minutes gathering responses.
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UNIT 3 : HYGIENE
9. Acknowledge to participants the amount of water required to wash hands at each critical moment
can be a major barrier to families actually practicing hand washing. Tell them that it is the job of the
outreach worker to help families figure out how.
10. Spend another two minutes and facilitate a discussion with the participants about what they
might say to a family that feels that it doesn’t have enough water to wash hands.
Record the key messages on the flipchart. Make sure you get their ideas in their own words.
If the discussion is stuck, guide it by asking:
l How could a CHV work with a family to prioritize certain times for hand washing over others
from the list?
l Has anyone seen or heard of any devices that let you wash your hands using a small amount
of water?
l Tell participants that you will later review how to make and use a device that is called a tippy
tap or “leaky tin”, which helps save water when hand washing. Do not spend much time
discussing tippy taps now since they will be covered in the next session.

1. Ask participants to discuss their thoughts about talking with families:
l What did they learn about the amount of water necessary for hand washing?
l Do they think they can help a family find ways to address a lack of water availability? (Note that
they will be learning much more about tippy taps in the next session.)
The amount of water necessary for “ideal” hand washing is substantial and can present a major barrier
to hand washing.
Even when people know that they should wash, they frequently don’t because there is simply not
enough water. Remind them that CHVs working with families can do as much as possible to help
families find ways to practice hand washing, even when water is scarce. These strategies include
helping families prioritize times for hand washing and using a tippy tap to conserve water.
3. Link to the next section by saying they are going to look at how to build a tippy tap or leaky tin.
RActivity 8:
Tippy Tap

Tell participants that during this session they are going to learn how to build a tippy tap. They will
have the chance to see how a tippy tap is made and will work on building a tippy tap at their tables (if
materials are available).
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UNIT 3 : HYGIENE
1. Ask participants if people in their community have enough water for their needs. If not, ask the
participants what people do to conserve or minimize the use of water.
2. If water is scarce or has to be carried to the house from an outside water source, mention that one
way to help economize water for hand washing is to use a tippy tap.
3. Explain that in previous sessions they focused on when and how to wash hands. In the last
module, they saw how much water it takes to wash hands well. Say that often water is scarce in the
community or has to be hauled long distances to the household and that by building tippy taps,
families can do effective hand washing with just a little bit of water.
4. Having a tippy tap in one or more key places near the house is a good reminder that hands should
be washed and enables people to do so more easily. Ask where people should place tippy taps.
(The best places would be just outside the latrine and in the kitchen area.)
RActivity 9:
Demonstration of building a Tippy Tap and Leaky Tins
A tippy tap is a simple handwashing device made of locally available material and is very easy to
build. Materials consist of:
l 3-4 sticks
l Wire/string
l 3-5 litre jerrycan
l Panga for digging holes
l Soap dish.
Large Group Demonstration (20 min)

1. Invite everyone to stand around the table/field
2. With the poster in view, build a tippy tap, following the steps on the poster.
3. Once the tippy tap is built, have a volunteer wash his or her hands using the tippy tap. Catch the
waste water.
Compare this to the amount of water used when pouring from a jug.
4. Calculate as a group how much water it would take for the whole family to wash their hands now.
Compare to the other amount calculated.
Group Task (30 min)

Divide the participants into 3-4 groups.
1. Have each group build a tippy tap.
2. Once each group has a tippy tap, hang them up and use them if time permits.
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UNIT 3 : HYGIENE
3. Initiate a discussion of how they might introduce this concept into their communities.
4. If feasible, allow some participants to use the tippy taps to wash their hands. Ask for their reactions;
e.g. “How did you find it washing your hands using the tippy tap?”

1. Discuss as a group how participants could us this in discussions with the households they visit:
l What did they learn about building tippy taps?
l What materials are available in the community for building a tippy tap?
l Do they think they can demonstrate this in the community?
l What other materials could be used to make hand washing stations? (e.g. pots, buckets with
taps, etc.)

l Tippy taps are easy to build.
l Tippy taps allow people to wash their hands using very little water.
l Tippy taps may be made out of locally available materials.
l Tippy taps remind us to wash our hands and help us to do it better.
l Good places to place a tippy tap are in the food preparation area and near a latrine.
3. Link to the next section by saying the next session will be a hand washing synthesis
Steps for building a tippy tap

1. Start out by digging 15 centimeter holes for the posts to sit in. Space them about half a meter apart
from one another.
2. Cut the wood to the post’s desired length, wrap the bottom parts with the plastic bags (this
prevents the wood from rotting) and then put them in the ground. Fortify the stability of the posts
by filling in the remaining empty space in the holes with a mixture of rocks and dirt.
3. Next, unscrew the lid of the jerrycan and poke a hole in the top large enough for the string to pass
through. Tie one end of the string to the wire. Thread the string through the hole so that the wire
sits snugly in the underside of the lid.
Poke a hole about 3/4 up the side of the jerrycan opposite of the handle. This is the spout where
the water will come out.
4. Slide one of the slender pieces of wood through the handle of the jerrycan. Make sure that it can
rock back and forth in the middle of the beam. If the stick is too big, whittle it down. Nail one side
of the beam into the top.
5. Extend the string to the ground and tie a piece of wood to the end of it. The tippy-tap can then be
tipped using your foot on the piece of wood like a foot pedal.
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UNIT 3 : HYGIENE
Tippy tap
Types of leaky tins
Tin Can
l Make a hole on side of tin can near bottom l To start water flow: pour cup of water in can
l Hang can l To stop water flow: let water run out
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MODULE
Hollow Tube
l Make hole in container l To start water flow: remove plug/cap
l Insert hollow tube (pen casing, pawpaw l To stop water flow: cover/plug tube
stem) in hole
l Find plug/cover for tube (pen cap, stick)
Screw Top with Hollow Tube

l Make hole in side of screw top bottle
l Insert tube into hole
l To start water flow: loosen screw top
l To stop water flow: tighten screw top
Ask participants which is better in fighting disease when handwashing. Tippy Taps or Leaky tins?
As them to give reasons for their answer.
The facilitator to summarize using the following key points.
Key points : Tippy taps

l Tippy taps are superior to leaky tins
l Leaky tins allow re-contamination when closing the tap
l Tippy taps have no re-contamination since you do not touch the
container, you just tip the device using a foot pedal, providing for
hygienic hand washing and water conservation
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UNIT 3 : HYGIENE
RActivity 10:
Strategies for proper hand washing
1. Ask participants what key points they remember regarding when and how to wash hands, how
to dry hands, how much water and time it takes, and how to build a tippy tap (if that session was
done). Make sure you have the flipcharts from the previous hand washing sessions hanging where
participants can see them.
2. Tell participants that during this session they can consolidate their thoughts about hand washing.
At the end, they will have a clearer idea of the strategies they can promote for proper hand washing
with soap.
3. Discuss further about the techniques on hand washing with soap.
Small Group Activity (40 min)

1. Move the participants so that they are sitting with others from their village or area, if appropriate.
Post or distribute copies of the Hand Washing Matrix (not necessary if not available).
2. Ask each group (or individual participants) to think about the following:
l Based on what they’ve learned about the importance of hand washing with soap, why is this
an important practice to promote?
l Who are some of the potential audiences they should be working with (individuals, families,
groups, schools, and children)? Be specific.
l What are some of the prevalent current practices regarding hand washing with soap?
l What could the community members be doing instead of some of the current (not so ideal)
behaviors?
l What is the current practice with soap in the household? Where is it kept, who keeps it and
how is it used?
l What are some things that make it hard to change people’s behaviors?
l What are some things that make it easier for people to change their behavior?
l Which, of the activities they saw demonstrated, might they do in their community?
3. Have participants practice negotiating with family members in their community to improve their
hand washing practices. Do a simulation with someone else. Then change roles. Have participants
talk about the potential problems and solutions they discussed.
Share information in the following table with the participants.
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Barriers to Handwashing What CHVs can do to address this barrier
People don’t know how important Explain/teach/demonstrate the concept of

the practice is. They don’t connect dehydration—that diarrhea leads to children losing
so much water that they get sick and can die.
dirty hands with diarrhea, and/or they
Mention what happens to crops when they don’t
consider diarrhea a “normal” and not get enough water. Acknowledge that children with
dangerous condition. diarrhea are too common now, but that it doesn’t
have to be that way—one key way to reduce
diarrhea is good hand washing.
Hands don’t look dirty. Use coughing and sneezing in hand exercise.
Soap is not easily available to First try to motivate people to purchase hand soap,
purchase or affordable. even if it is difficult. Note that the bar of soap can be
cut into smaller pieces, so one bar can be “spread”
across multiple hand washing stations. If people
feel that they cannot buy soap, then ask them to
wash with ashes, sand, or mud…whichever is most
acceptable and available.
People have poor access to water, so Consider three basic ideas together with the
they don’t want to use too much for mothers or families: (1) use a tippy tap or some other
things like hand washing. watersaving device; (2) figure out a way to get more
water for the family; (3) when water is most scarce,
wash only at the most critical times (in most places,
after defecating, cleaning a baby’s bottom or diaper,
or otherwise coming into contact with faeces).
Try to motivate hand washing with soap as often as

People are too busy. possible, but emphasize the most critical times.
People don’t have a good place to Encourage every family to prepare at least one
hand washing station, ideally one at the latrine
wash where all the supplies (soap,
and one where food is prepared; engage respected
water, etc.) are located together. community members to do the same.
People don’t wash at critical times. Teach what the most critical times are; prioritize
critical times if washing at all recommended times is
not acceptable or feasible.
People don’t wash thoroughly enough. Organize public demonstrations, using children and
adults, to model good hand washing techniques.
People dry hands on whatever soft Encourage people to air dry.

material is available (often dirty).
HIV stigma. Not a danger as long as precautions are taken.
Location of hand washing facility. Must be conveniently located to promote hand

washing with soap practice.
7
MODULE
UNIT 3 : HYGIENE
HOME AND FOOD HYGIENE (2 HRS)
RActivity 11:
Determinants of Hygiene
Place the participants into groups and ask them to discuss and come up with factors that enhance
good hygiene practices. Let them present their findings and then compare with the listed points below:
Key points: Hygiene Practices

l Literacy level – health education and health promotion level
l Economic empowerment – availability of adequate clean
and safe water, creation of income generating activities
l Infrastructure (provision of good roads for health works to
reach the community)
l Environment
l Security (e.g. access of toilets in slums at night)
l Culture
l Government policies
l Availability of adequate clean and safe water
Personal Hygiene
Ask the participants to brainstorm on the role of the CHV and household member in maintaining
hygienic practices.
As you list down their responses, check whether the following points are mentioned by them, and if
not, add as you summarize their responses.
l Hand washing with soap before eating and after use of toilet should be reinforced
l Households should provide hand cleaning materials
7
MODULE
UNIT 3 : HYGIENE
l CHV and household head should undertake routine personal hygiene for the households
they are in charge of
l CHV and household head should screen for ringworms, jiggers, lice and scabies.
Ringworms Jiggers Lice Scabies
Let the participants buzz in two’s on examples of hygienic practices for the home.
Compare their examples with the notes below:
Notes on Home and Hygiene
The community health worker should promote home hygiene which involves the following:
l Site pit latrines properly (30 metres away and downstream/downhill from water sources)
l Ensure houses are well constructed, thoroughly smeared with clay/cow dung/plaster
and properly ventilated
l Provide and use rubbish pits
l Provide cattle troughs and keep cows in a fenced enclosure
l Protect the environment – dispose of rubbish properly, burn plastic bags, keep water
sources clean, etc.
l Construct drainage channels around the house, so that water does not collect near it and
produce breeding grounds for mosquitoes
l Cut vegetation and bushes around houses to deter mosquitoes and other vermin (rats
etc.)
l If chickens and domestic animals are kept in the same house with human beings they
should be kept away from the kitchen and eating and sleeping places
l Protect both public and private water points, e.g., wells, springs
l Plant trees.
7
MODULE
UNIT 3 : HYGIENE
RActivity 12:
Share the following table with the participants. Divide them into several groups and give them
flipcharts. Allow 1 or 2 to present and compare their responses with the table.
Distribution of Household Vector in Kenya
Disease/ Vector(s) Location Hygienic practices

Conditions
Painful bites, Bedbugs Pastoralists, Washing clothing and

allergic reactions slums, boarding beddings using hot
institutions water and detergents.
Airing of beddings in
the sun.
Diarrhea, Trachoma House flies Countrywide Regular face washing,

proper disposal of
waste, keeping away
livestock from dwelling
unit, improving and
maintaining of VIP
latrines.
Wounds, secondary Jiggers Jigger endemic Daily washing of

infections, disability counties feet, wearing shoes,
domestic hygiene,
regular cleaning
and wetting floors,
smearing of floors and
walls with cow dung or
cement.
Diarrhoel, Hepatitis A, Cockroaches Countrywide Covering of food well,

Asthma keep cooked food
covered, cleaning of
utensils and cupboards,
improvement of
latrines.
7
MODULE
UNIT 3 : HYGIENE
RActivity 13:
Have a plenary session to interrogate the common food hygiene safety practices in the community.
Let the participants participate openly. Try to make the session as interactive as possible.
Let them present their findings and then compare with the listed points below.
Food Hygiene safety
l Always cover your hair during preparation of food
l Keep your nails short
l Wash hands with soap and water
l Prepare food on a clean surface and use clean utensils
l All food that is eaten raw should be cleaned with safe water
l Wash vegetables well before cutting
Appropriate hygiene practices during cooking
l Keep the food covered during cooking
l Cook in a clean environment
l Used utensils should be washed in hot water using detergent.

Always dry utensils using a dish rack.
l Always cover prepared or cooked foods intended for later use to

avoid insect and dust contamination. Always reheat food before
eating it.
l Left over food should be properly disposed of and not recycled

for use the next day
7
MODULE
Bibliography
Ministry of Health (2007). Linking Communities with Health System: The Kenya
Essential Package for Health at Level 1. A Manual for Training Community Health
Workers – (Pg 6- 10)
P Ngatia., N. Mwita,. S. Kangethe,. H. Waweru,. T Nyakwana,. S. Nzyuko (2010).

Comprehensive Curriculum and Implementation Guide for Training Community Health
Workers in Africa, AMREF.
G. Rakungu (2011). Environmental Health for East Africa.
Mara,. Feacher,. Cainecross,. (1996). Environmental Health Engineering in Tropical

Countries.
MOH (2011), MOH/USAID WASHPlus Training Guide for Community Health Workers in
WASH-HIV Integration.
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MODULE
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MODULE
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MINISTRY OF HEALTH
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Facilitators Guide

Division of Community Health Services

AICAD The African Institute for Capacity Development

AMREF African Medical Research Foundation

CHEW Community Health Extension Worker

CHSFP Community Health Strategy Focal Person

CHV Community Health Volunteers

CLTS Community Led Total Sanitation

DCHS Division of Community Health Services

FHI 360 Family Health International

JICA CHS Japan International Corporation Agency- Community

MDGs Millennium Development Goals

MOH Ministry of Health

NGO Non-Governmental Organization

NHSSP National Health Sector Strategic Plan

PET Polyethylene Terephthalate

PVC Polyvinyl chloride

SODIS Solar Water Disinfection

STI Sexually Transmitted Infections

UNICEF United Nations Childrens Fund

USAID United States Agency for International Development

UTI Urinary Tract Infection

WASH Water, Sanitation and Hygiene

Health is a major component in the socio-economic development of any community.

Extensive consultations among various departments, divisions and stakeholders

Mark Bor, MBS

The CHV training is organised in Modules which should be applied incrementally

l Section One: Basic Modules

l Section Two: Technical Modules

Dr. Kepha Ombacho, MBS

The development of the Manual was preceded by extensive discussion by partners,

Various stakeholders and reviewers provided technical reviews and suggestions to

David K. Njoroge MOH-HRD Clare Mwangi MOH-DCHS

Akiko Chiba JICA CHS Project Kenneth Ogendo MOH-DCHS

John O Osir MOH-CHEW Anne Thitu MOH-DCHS

Ben Lodung’okiok MOH-CHEW Samuel N. Njoroge MOH-DCHS

Jacob Kioko MOH-CHEW Peter Wanjohi MOH Department of

Georgiadis G. Mwambia MOH-CHEW Dr Kepha Ombacho MOH Department of

Githinji Miginyo Nyeri CHSFP John Kagira USAID WASHPlus/FHI 360

Dr James Mwitari MOH-DCHS Evelyn Makena USAID WASHPlus/FHI 360

Samuel G. Kiogora MOH-DCHS Dennis C. Langat USAID WASHPlus/FHI 360

Jane Koech MOH-DCHS

Key Community Practices l Understanding the sources of water in the community

l To carry out health promotion activities including

Reference Wash Manuals e.g. wash modules

Number of Units Three

Methodology Role-play, demonstrations, group discussions, stories,

Duration: · 7 hours 40 minutes

Methodologies: Brainstorming, discussion, demonstration and role-play.

Materials: Newsprint, Felt/Marker pens, Masking tape, Newspaper cuttings, Pens,

Unit Session Plan

20 min Purpose of this unit Story

10 min Importance of Water for Health Brainstorming

2 hrs Improving Water quality in the Community Discussion and

2 hrs Causes of Water Contaminations Group Work and

40 min Water Treatment at Household Level Discussion and

2 hrs Demonstration of Water Treatment Methods Demonstration

30 min Safe Water Storage Group Work

UNIT 1 : WATER SAFETY

ACTIVITIES AND FACILITATION STEPS

Read the following story of Timothy.

In their village, water was pumped up from a deep borehole. A development

The following points should be answered during the discussion.