Module 4

Water, Sanitation and

Hygiene Promotion

Number of hours: 5 hours and 40 minutes Number of Days: 01

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Table of Content

1. Emergency Water Supply

a. Introduction to water supply
b. Water supply components
c. WatSan emergency response tools
2. Household Water Treatment
a. Why household water treatment and safe storage?
b. Methods of water treatment
c. Safe storage
d. Training
e. Follow up training
3. Emergency Sanitation
a. Excreta disposal
b. Solid waste management
c. Waste water management (drainage)
d. Vector control
4. Hygiene promotion in emergency
a. Why do we need hygiene promotion?
b. Selection and distribution of hygiene kits
c. How do we do hygiene promotion in emergency?
d. Hygiene promotion box
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Session 1 – Emergency Water Supply

Objective of this session:

1. Understand the objective of water supply in emergencies
2. Understand the basic principles of water treatment and supply.
3. Identify key water supply tools used by the RC/RC movement in emergencies

Session Plan
Timing: 1.5 hours
Methods: presentation and discussions.

Time Topic Methodology

15 minutes Introduction to WatSan in  Introduce RC/RC movement water and
Red Cross and Red sanitation policy and India Red Cross
Crescent movement Society’s NDWRT (National Disaster WatSan
Response Team).
15 minutes Introduction to water  Discuss the importance of water supply in
supply emergencies.
 Use Sphere to discuss the standards
relating to access, water quantity and water
quality.
40 minutes Water supply components  Ask participants the different options for
water supplies, highlighting groundwater as
being the safest source and why.
 Explain the applicability of rainwater
harvesting
 Introduce principles of water treatment and
water quality and ask what ‘safe’ water
means.
 Discuss the aspects of water storage and
distribution and share experiences and
challenges.
20 minutes WatSan emergency  Introduce the emergency response tools
response tools available for water treatment.
 Discuss the use of mass treatment and
household treatment.
 Emphasise that NDWRT should be involved
to operate the mass water treatment units.
 Discuss content of a Kit 2

Tools and Resources required

 Power point presentation; flipcharts; markers; tape and chart stands.
 Facilitator (Nominally someone experienced in facilitating NDWRT Training
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Key Messages
1. All of the water supply components should be considered and designed with a holistic
approach to ensure that we provide safe drinking water to the population.
2. The water treatment units should be operated and maintained by trained personnel.
3. Never ever distribute Kit 2 items (especially chemicals) without training people in their
use.
4. Any implementation or distribution should be accompanied by hygiene promotion to
reach the desired impact.

List of Resources
1) Presentation: Module 4 S1_Emergency Water Supply
2) Additional reference material: Module 4 S1_IFRC Disaster Response Kit 2

Content
1. Red Cross Red Crescent Movement WatSan Policy
Access to safe water and sanitation is a human right as declared by the United Nations.

In its efforts to alleviate human suffering, RC/RC movement provides water and sanitation
services as part of the overall health and care interventions for vulnerable people both in
ordinary times as well as in emergencies. The overall goal of the WatSan Policy is to
‘improve health & restore dignity by provision of adequate safe water, sanitation and
hygiene promotion’.

Water and sanitation is a health initiative, clearly defined and seen as one of the most
important aspects of preventive/public health. Therefore, community-based health care can
not be considered without addressing the issue of water and sanitation coverage.

2. WatSan in Emergency Health

The range of health problems found in emergencies is often similar to that occurring in many
developing communities around the world. Common problems include diarrhoea,
nutritional deficiencies, pneumonia and other respiratory infections, malaria, worms,
anaemia, tuberculosis, measles, eye and skin infections and genitor-urinary problems.
Although epidemics occur relatively infrequently, outbreaks of diseases such as measles or
cholera pose a serious threat.

Faecal-oral diseases such as diarrhoeas can be caused by drinking contaminated water, by

poor personal hygiene (not washing hands at critical times) and by poor food hygiene
(improper cooking, contamination by flies). These diseases can be particularly virulent in
overcrowded unsanitary conditions and are frequently the major causes of illness and death
in epidemics.

Water, sanitation and hygiene promotion activities during emergencies aim to prevent
infection of the above mentioned diseases by interrupting the routes of disease
transmission.
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3. Introduction to Water Supply

People need safe water for drinking and cooking. Adequate amount of water is also
required in maintaining personal hygiene and health. The minimum quantity of drinking
water required for human survival will vary, depending upon the climate, the amount of
food intake, and human activity. But how do we know how much water to cater for in an
emergency?

SPHERE
The SPHERE standard was initiated in 1997 by the RC/RC movement in cooperation with
other Non-Government Organisations. It identifies the minimum standard of necessities
required by any human being during a disaster to maintain health and dignity. Many
humanitarian organisations today refer to SPHERE as a guideline to improve the quality of
their services during disaster response.

There are six chapters in the SPHERE standard that is in reference to water, sanitation and
hygiene promotion. The SPHERE Standard stipulates that the minimum amount of safe
water for drinking required by each individual during an emergency is 3L, and the total
amount required per person per day is 15L.

The SPHERE Standard also stipulates that no one should have to walk for more than 500m to
collect safe drinking water, and that the water supply should have sufficient pressure and
flow to fill a 20L container within 3 minutes. There should be 0 Faecal Coliform / 100ml of
water supply to protect the health of the people served. This can be achieved by different
types of treatment that will be discussed further in this chapter. To ensure that the water is
not re-contaminated upon collection, SPHERE also suggests dosing the treated water with
chlorine that provides a free chlorine concentration of 0.5mg/L at the tap.

4. Water Supply Components

There are five important components to any water supply system. These include:
 Water Source
 Water Quality/Treatment
 Water Transmission
 Water Storage
 Water Consumption

4.1 Water Sources

Water sources fall into three general categories:

Rainwater – Rainwater is one of the easiest water sources to harness and often require
the least treatment to achieve drinking water standard. However, it is very weather
dependent. Hence, it is generally not considered as a reliable source during complex
emergencies (in terms of providing sufficient quantity over a fixed period) especially for a
large displaced population.

Surface water – Surface water from lakes, ponds, streams, reservoirs and rivers have the
advantage of being accessible (water easily collected) and are predictably reliable and
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plentiful. They have the disadvantage of generally being microbiologically unsafe, and
therefore, requiring treatment.

Groundwater – Deep (generally clear, found in wells, bores) and shallow (subject to
seasonal variation). Groundwater from wells and springs tends to be of higher quality
(having undergone natural soil filtration underground). However, it is relatively difficult
to extract. More technology and energy is needed (compared with other water sources)
to bring water from within the earth up to the surface. Some groundwater source may
be high in metal content such as Arsenic and Iron, which needs to be addressed prior to
supplying to mass.

The following factors are important when selecting the type of water sources for
displaced population:
 the quality of the water source
 the reliability of available water sources
 the water needs in relation to population size
 the intended length of intervention
 the locally available skills and resources
 the capacity of the implementing agency
 ease of accessing and distributing the water from source to tap

Water Source Protection

It is crucial to protect the water sources from contamination (or further contamination)
by faecal contamination through human or livestock defecation. In conflict areas, it is
also important to protect the water source from poisoning. Here are some suggestions
on how to protect the water sources:
 Fencing – Fencing the area around the water source to prevent livestock and people
from coming into contact with the water source.
 Signage – Erect signage to inform public to keep out of the protected area.
 Sealing – If possible, seal the water source. This is generally applicable to wells and
springs.
 Locate defecation areas far from water source
 Provide security by employing a watchman to protect the water source.

4.2 Water Quality and Treatment

Most countries have their own standards stipulating what the drinking water quality
should be. In the event where Local Government Standards are not available, the
following references could be used as guidelines:
 World Health Organisation (WHO) Water Quality Guidelines
 SPHERE standards
 Risk Management approach

Turbidity is a measure of how clear water is due to the presence of suspended

particulates. The more total suspended solids in the water, the murkier it seems and the
higher the turbidity. The less total suspended solids there are in the water, the clearer,
the water is the lower the turbidity. Turbidity is considered as a good measure of the
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quality of water. The turbidity of the water source must be low to ensure disinfection is
effective.

Turbidity is measured in NTU (Nephelometric Turbidity Units). Turbidity of drinking

water must not be more than 5 NTU.

Faecal Coliform is an indicator of faecal contamination bacteria; more specifically of E.

coli which is an indicator microorganism for other pathogens that may be present in
faeces. Presence of faecal coliform in water may not be directly harmful to human
beings, but in an emergency environment is used as an indication of presence of human
or animal waste in water. The SPHERE Standards stipulates that there should be NO
Faecal Coliform in drinking water.

Disinfection is the process that kills harmful organisms using either physical (heat or Ultra
Violet light) or chemical (chlorine) disinfectants. The main difference between
chlorination and other physical disinfection methods is the chlorination provides residual
protection to continue to kill organisms.

The recommended residual chlorine in any water supply system during an emergency
should be 0.2 – 0.5 mg/L at the tap after 30mins contact time for effective disinfection.
The residual chlorine can be measured using pool tester.

“Contact time” is the time that it takes to effectively kill the harmful organisms through
contact with chlorine. The recommended contact time for all chlorination process is
30mins.

Why should we treat water?

The aim of water treatment is to treat water to a desired quality to provide safe drinking
water. But what is it that we want to treat?

Bacteriological – Bacteria are microscopic organisms found just about everywhere. Most
bacteria are harmless, but certain types can cause disease, sickness or other health
problems. Disinfectant using chlorination is the most common method to get rid of
bacteria presence in water.

Chemical – Most chemicals, when present in drinking water at low levels, are harmless to
human health. However, when they exceed the recommended levels, they can cause
health problems. The WHO Guidelines for Drinking-Water Quality include facts sheets
and comprehensive review documents for many individual chemicals with guideline
levels. It is often difficult to remove chemicals in water during emergencies. Therefore,
volunteers should avoid selecting water sources which are high in chemical content.

Physical – Most surface water sources are highly turbid due to the presence of dirt, mud,
grit and suspended solids that are collected from the earth surface during heavy rainfall
and subsequently washed into rivers and lakes. These solids can be easily removed from
water through straining or filtration.
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How do we treat water?

The types of treatments available include:
 Sedimentation – using gravity to settle the unwanted particles in the water
 Physical – using methods such as straining and filtration to physically remove
unwanted particles from the water.
 Chemical – using chemicals to help with the flocculation/coagulation process to assist
in removing the suspended solids in the water
 Disinfection - kills bacteria through chlorination, boiling etc

4.3 Water Transmission

There are many ways to deliver water body from one location to another. Below are
some of the commonly used components to deliver treated water to the affected
population:
 Gravity Fed Systems/Pumping Systems
 Pipes
 Pumps
 Fittings
 Jerry Cans/Buckets
 Trucks – Trucking water is one of the most problematic ways to deliver water during
an emergency. The advantage of transporting water using a trucking system is that it
allows reaching a bigger number and dispersed beneficiaries. However, the
disadvantage in this method is that it is expensive and difficult to manage.

4.4 Water Storage

During an emergency, affected population can be supplied with different containers to
store safe drinking water such as pots, jerry cans, buckets etc. They should also be
encouraged to use their existing household containers (if available) to store safe drinking
water.

The RCRC movement has a supply of big rigid and flexible tanks to store large capacity of
treated water prior to distribution point. The most commonly used tanks is Oxfam tank
T11 (capacity of 10,500L), onion tank and bladder tank.

Oxfam Tank
The advantages of an Oxfam tank are:
 rigid (liner is protected by a corrugated sheet)
 large capacity of storage
 ideal for long term operation
 transportation is very easy (can be dismantled and packed into a custom made box)
 no need for tools

The disadvantages of an Oxfam tank are:

 requires tools during installation
 longer time of installation
 heavy and requires additional man power
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Figure 1.1: Oxfam Tanks

Flexible Tank
The advantages of flexible tank are:
 minimum space for storage
 very light
 transportation is very easy
 no need for tools

The disadvantages of flexible tank are:

 easily damaged
 requires a big clear and flat area

Figure 1.2: Onion Tank 5,000L Capacity Figure 1.3: Bladder Tank 5,000L Capacity

5. WatSan Emergency Response Tools

The response tools available for the RC/RC movement during emergencies include:
 WatSan Kit 2 – for 2,000 people
 WatSan Kit 5 – for 5,000 people
 WatSan Kit 10 – for 10,000 people
 WatSan ERU Module 15 – for 15,000 people
 WatSan ERU Module 20 – for 20,000 people
 WatSan ERU Module 40 – for 40,000 people
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What is in each kit?

Each kit contains different equipment and tools to cater for water treatment, water
distribution, sanitation and hygiene promotion. The kits are fundamentally the same but
differ in the type and size of equipment to cater for the population needs.

There are two categories of water treatment type: mass treatment and household
treatment. Mass treatment can be found in the larger kits or modules, where as the
household treatment is used for smaller population size.

5.1 Mass Treatment

The philosophy behind mass treatment is that water is taken from the best source
possible (river, pond, borehole) then purified at treatment plant and distributed by pipe
network or truck. Mass treatment is ideal for camp situations or high population
densities (urban or peri urban).

It is important to note that most of the equipment are expensive and should only be
deployed along with trained technical staff/volunteers to operate the treatment plant.

Figure 1.4: SETA water treatment plant Figure 1.5: NOMAD treatment plant

5.2 Household Treatment

When responding to a smaller and more disperse population, household water
treatment should be considered as the preferred intervention methodology to supply
safe drinking water in the immediate and short term. In this method, the water is
collected by the population, but is provided with means to treat water themselves.

It is important to note that prior to distributing any chemicals for household water
treatment, training must be provided to the beneficiaries with adequate follow up to
monitor adherence. An exit strategy should also be in place to plan and make
arrangements for long term safe drinking water supplies.
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Resource materials for this session:

1. PowerPoint presentation titled ‘1. Emergency Water Supply’
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Session 2 – Household Water Treatment

Objective of this session

1. Participants to be familiar with the household water treatment options and application.
2. Participants to be able to demonstrate and train volunteers/beneficiaries on how to
conduct household water treatment and safe storage.
3. Participants understand the need to monitor the implementation and report on
perceived impact.

Session Plan
Timing: 1.5 hours
Methods: presentation, group discussions, practical demonstration and group exercise

Time Topic Methodology

10 minutes Why household water • Ask the participants if household water
treatment and safe storage? treatment is safe? Also ask their views
on when and why would one choose to
use household water treatment?
• Use the flipcharts to note the correct
answers only
• Discuss the applicability of household
water treatment in emergencies
40 minutes Methods of Water Treatment • Distribute a copy of the household
water treatment and safe storage
manual to every participant and discuss
and explain treatment methods.
• Demonstrate treatment of a 10L bucket
of water using Aquatab or Waterguard
and then using PUR on a turbid water
source.
• Ask participants to drink the treated
water to demonstrate the willingness
to drink water that we ask beneficiaries
to drink.
• Discuss the confusion that can result
without proper training on use of
household water treatment products.
• Discuss exit strategy.
10 minutes Safe Storage • Ask the group if treated water can be
re-contaminated?
• Ask them to share common practices in
storing water.
• Identify good and bad water storage
practices and emphasise the
importance in training beneficiaries on
safe storage.
30 minutes Training and Follow up • Discuss the steps of an intervention
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Time Topic Methodology

Training involving Household Water Treatment
(training, distribution, follow up
training).
• Emphasise the importance of coupling
training with distribution and follow up
training.
• Conclude and summarise the key
messages of the session.
• Divide the participants into groups and
ask them to develop a plan to
distribute water treatment materials,
train the beneficiaries on how to use
the materials, and monitor the usage of
the materials. Groups to present plan
and demonstrate the training session.

Tools and Resources required

 Chlorine tablets or solution (Aquatabs or Waterguards)
 PUR sachets
 Clear Buckets (at least 4 x 10L)
 White cotton clothe
 Spoon / stirrer
 Water source (clean water and turbid water)
 Household Water Treatment and Safe Storage Manuals for all participants
 Facilitator x 1 (Nominally someone experienced in facilitating NDWRT Training
 Flipcharts
 Markers
 Power point

Key Messages
1. Consider household water treatment in emergencies involving disperse population with
issues of quality not quantity of water
2. Choose your product and dosage well
3. Never ever distribute chemicals or products without training people in their use
4. Safe water storage is equally important to prevent spread of water borne diseases

List of Resources
1) Presentation: Module 4 S2_Household Water Treatment and Safe Storage in
Emergencies
2) Additional reference material: Household Water Treatment and Safe Storage in
Emergencies Manual
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Content
1. Why Household Water Treatment and Safe Storage?
Using water from a clean source which is stored in a safe manner is important for human’s
health. However, this may not always be available, especially during emergencies. Hence, it
is crucial to provide the affected population an alternative means of accessing safe water.

Household water treatment enables the affected population to treat dirty water quickly and
safely at a household level. The techniques used are simple and can be applied immediately
after some basic training.

Household water treatment is often a temporary measure undertaken during emergencies

(especially in a community where population is dispersed) until the long term water source
can be improved.

2. Methods for Water Treatment

There are three main types of household water treatment:
1. Disinfection – making sure that water is free from disease causing germs. This may be
done by chemicals, heat, or even sunlight.
2. Sedimentation – allowing dirt to fall to the bottom of a water container over time.
3. Filtration – physically removing dirt by passing the water through a material such as
ceramic or sand.

2.1 Straining
Straining involves pouring muddy or dirty water through a piece of fine, clean cloth
(nominally cotton clothe which is not see through) to remove dirt, insect larvae and
other suspended solids in the water.

Straining alone is unlikely to make water from a contaminated source completely safe to
drink. But it is an important first step to improve the effectiveness of all household
water treatment.

2.2 Boiling
Boiling is a traditional method of treating water which can be easily done by most
population given that they have sufficient heating source. When perform correctly,
boiling will kill all organisms that cause disease. However, it leaves the water tasting flat
which some people may not be used to. This can be mitigated by aerating the water
after adding a pinch of salt.

In order to effectively kill all the disease causing organisms, the water must be brought
to a rolling boil for 1 minute in low elevations and 3 minutes in high elevations. Note
that it takes 1 kilogram of firewood to boil 1 litre of water for one minute. Thus, this
method should not be introduced in areas where heating source such as fire wood is
scarce. Note also that boiling will not make water less cloudy or provide ongoing
protection against re-contamination. Therefore, boiled water should be stored safely
and used within a few days.

2.3 Solar Disinfection

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Exposing water to sunlight will destroy most organisms that cause disease, but only if
exposed long enough (at least 5 hours on a non-cloudy day centred around midday).
Although this method is easy to use and does not require specialised equipment or
material, the process takes a long time and is very weather dependent. Therefore, this
method should not be introduced during rainy season. Similar to boiling, solar
disinfection does not provide ongoing protection against re-contamination. Thus,
treated water should be stored safely and used within a few days.

2.4 Chemical Disinfection

There are many chemicals (which differs in effectiveness and safety) capable of
disinfecting water. The most commonly used chemicals for household water treatment
are chlorine tablets and WaterGuard liquid. These products are easy to use and normally
have instructions on the packaging. Be aware that the instructions may not be in a
language that is widely used by the effected population or they may not be able to read.
Hence, training would still be required.

Unlike boiling and solar disinfection, the chemicals may not be locally available.
However, if the chemical treatment is conducted correctly, it will provide residual effect
of disinfection, which gives some protection against contamination after treatment.
Some people may be sensitive to the smell or taste of chlorine. This can be easily treated
by airing the water container and exposing it to heat for a short period of time to release
the extra chlorine.

2.5 Sedimentation
Sedimentation is effective in clearing muddy water by allowing the dirt to fall and settle
at the bottom of the jars / pots. However, unless chemicals are used, it does not treat
the water to a safe drinking standard. Thus, further disinfection is still required before
consuming the water.

Muddy water can be made clear by using either the Three Pot Method or chemical
sedimentation. Some of the limitations of these methods include:
 These products are more complicated to use and require more training and
follow up.
 These products are many times more expensive per litre of water treated than
chemical disinfection products and should only be used when water is muddy or
no other product is available.
 People will need more than one container to properly use these chemicals.

2.6 Candle Filters

Candle filters are not normally used in emergencies, but they are very effective in
treating water at a household level. The candle filters are made of ceramic which
screens harmful material when water passes through the filter at slow rate. When the
clean water flow becomes too slow, it is an indication that the candle is clogged. The
candle should then be unclogged/maintained by brushing the candle with water and
disinfected by putting in a pot of boiling water to kill all the germs.
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Candle filter is easy to use, but is expensive and fragile. If the source water is very dirty,
it may take a long time to treat and maintenance requirement may become very
frequent. There is no residual effect on this treatment, so safe storage is required to
avoid re-contaminating the treated water.

2.7 Sand Filters

Filtration through sand is a fast and simple pre-treatment option that reduces the
amount of dirt in water and makes disinfection more effective. For longer term water
treatment, a biosand filter can be used to filter water through sand and a biological
layer that develops on the top of the filter. Both sand and biosand filters can be cleaned
when it becomes clogged. Because the biological layer requires time to establish, the
filter is normally not effective at the beginning of use or immediately after a clean.

Although filters are simple to use, they required hands on training when they are
distributed to ensure that the filters are regularly maintained. Hence, filters are rarely
used to respond to emergencies.

3. Safe Storage
All efforts to make water clean are pointless if the water is improperly stored or handled.
Narrow necked containers prevent contamination but are difficult to clean. Wide necked
containers are easily contaminated but easily cleaned. In emergencies, people will use
containers they already own or containers that they are provided with during the
intervention. Or both. Work with what you have.

4. Training
Chemicals should NEVER be distributed without training people in their use. Make a training
plan before the distribution and work with people to find the right dose for their water and
their container. If the people are unfamiliar with the products, they may not trust the
methods. Demonstrate how to use the product and then drink the treated water in front of
them to show your confidence in the methods. Allow them to practice using the products
and methods in front of you and allow them to ask questions and raise concerns.

5. Follow Up Training
One lesson on how to conduct household water treatment is not enough. Follow up training
and monitoring should be carried out after the initial training. During this follow up training,
you and your field team are looking for:
 People’s satisfaction regarding the product selected
 Correct use of the products
 People’s hygiene practices at household level in relation to water handling and
storage.
It is recommended to include hygiene promotion with training of household water
treatment and safe storage to encourage behavioural change of the people. Note that
awareness and health messages may not be enough to change behaviour. Cultural and
traditional believes should also be considered when implementation hygiene promotion.

Resource materials for this session:

2. PowerPoint presentation titled ‘2. Household Water Treatment and Safe Storage in
Emergencies’
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Session 3 – Emergency Sanitation

Objective of this session

1. Participants understand the pathway of disease transmission and blockages.
2. Understand the key standards, indicators and guidelines for sanitation in SPHERE.
3. Understand the basic principles of excreta disposal in emergencies.
4. Identify key sanitation tools used by the RC/RC movement in emergencies.

Session Plan
Timing: 1 hour
Methods: presentation, group discussions, product demonstration and group exercise

Time Topic Methodology

45 minutes Excreta Disposal • Ask the participants what are the main
causes of death in emergencies? Discuss
links of health to WatSan.
• Use whiteboard or flipcharts to introduce
the F-diagram, and demonstrate the
pathways of disease transmission as well as
the links to blocking the pathways through
“WatSan hardware and software”.
• Introduce different options for excreta
disposal in emergencies. Comment on the
applicability of each option.
• Showcase the products available in Kit 2.
• Divide the participants into groups and ask
each group to discuss the importance of
maintaining latrines and some of the
challenges.
5 minutes Solid Waste • Discuss different options for Solid Waste
Management Management in emergencies. Comment on
the applicability of each option.
5 minutes Drainage • Discuss importance of providing drainage
and link to health by minimising vector
breeding ground.
5 minutes Vector Control • Discuss different options for Vector Control
in emergencies. Stress the importance of
training when distributing products. Share
common mistakes/misuse of products.

Tools and Resources required

 1 set of disaster emergency sanitation response kit from Kit 2
 Facilitator x 1 (Nominally someone experienced in facilitating NDWRT Training
 Flipcharts
 Markers
 Projector
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Key Messages
1. Providing proper sanitation is equally important as providing safe water supply in
emergencies.
2. Remember to train the people on use and maintenance of facilities.
3. Always couple hygiene promotion to sanitation implementation

List of Resources
1) Presentation: Module 4 S3_Sanitation in Emergencies

Content
Sanitation in Emergency
It is generally accepted that excreta disposal is given less priority in emergencies than other
humanitarian interventions such as health care, food and water supply. This is despite the
fact that many of the most common diseases occurring in emergency situations are caused
by inadequate sanitation facilities and poor hygiene practice. Many aid agencies are aware
of these facts and are now giving a greater emphasis to sanitation, especially excreta
disposal.

Sanitation in emergency encompasses excreta disposal, solid waste management, waste

water management (drainage) and vector control.

1 Excreta disposal
Inadequate and unsafe disposal of human faeces can lead to the transmission of faecal-oral
disease, can result in the contamination of the ground and water sources, and can provide
breeding sites for flies and mosquitoes which may carry infection. In addition, faeces may
attract domestic animals and vermin which spread the potential for disease. It can also
create an unpleasant environment in terms of odour and sight.

While the provision of safe drinking water is also essential for the protection of public
health, the importance of excreta disposal cannot be overestimated. Diarrhoeal diseases,
transmitted via the faecal-oral route, account for 17% of all deaths of children under five
worldwide (WHO, 2006) and the risk of occurrence increase significantly in most emergency
situations. i

Children under five years of age are most at risk from communicable diseases since their
immune systems have not developed fully. Malnutrition resulting from food insecurity and
chronic emergencies increases this risk further. Since young children are unaware of the
health risks associated with contact with faeces, it is essential that faeces are safely
contained.
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Figure 3.1 demonstrates the

spiral relationship between
malnutrition and infection;
inadequate dietary intake leads to
weight loss, lowered immunity
and mucosal changes. This
affects the incidence, duration
and severity of many diseases,
particularly diarrhoea or
dysentery, which in turn may lead
to appetite loss, nutrient loss and
mal-absorption further
exacerbating malnutrition. So, be
aware, as communicable disease
indicators have important
Figure 3.1: Causes of Death in Emergencies (Worldwide)
interactions with indicators in
other sectors: such as nutrition, water and sanitation.

The introduction of safe excreta disposal can reduce the incidence of intestinal infections
and helminth infestations. Excreta-related communicable diseases include cholera, typhoid,
dysentery (including shigellosis), diarrhoea, hookworm, schistosomiasis and filariasis, as well
as roundworms, poliomyelitis and hepatitis. The likelihood of all these diseases, and
especially epidemics such as cholera, increases significantly when a population is displaced
or affected by a disaster.

Transmission of excreta-
related diseases is largely
faecal-oral or through skin
penetration. Figure 3.2
illustrates the potential
transmission routes for
pathogens found in excreta.
The infectious agents that
cause diarrhoea are usually
spread by the faecal-oral
route, which includes the
ingestion of faecally
contaminated water or food,
person-to-person
transmission, and direct
contact with infected faeces. Figure 3.2: F-Diagram

Poor hygiene practice, particularly involving food and hands, are often a major cause of
disease transmission, even where appropriate excreta disposal facilities are in place. For this
reason it is difficult to obtain a direct correlation between the incidence of excreta-related
disease and the provision of appropriate facilities.
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Water, Sanitation and Hygiene Promotion

1.1 Sphere Standards and Indicators

Sphere project is a humanitarian chapter which prescribes the minimum standards in
humanitarian response. It was initiated in 1997 by non-government organisations
(NGOs) and International Red Cross Red Crescent Movement. The aim of this initiation is
to improve quality of humanitarian actions during disaster response and to be held
accountable for them.

The minimum standards developed were based on two core beliefs:

1) Those effected by disaster or conflict have the right to life with dignity and thus right
to assistance
2) All possible steps should be taken to alleviate human suffering arising out of disaster
or conflict

For excreta disposal, the following two standards apply:

Standard 1: Environment free from human faeces – The living environment in general
and specifically the habitat, food production areas, public centres and surroundings of
drinking water sources are free from human faecal contamination.

One of the main indicators for this standard include all trenches and soak away pits are
at least 30m away from groundwater source, and at least 1.5m above water table.

Standard 2: Appropriate and adequate toilet facilities – People have adequate,

appropriate and acceptable toilet facilities, sufficiently close to their dwellings, to allow
rapid, safe and secure access at all times, day and night. .

Some of the main indicators for this standard include:

 Max. 20 people per toilet.
 Toilets are less than 50m away from dwellings.
 People wash their hands after using latrines and eating or preparing food.

1.3 Sanitation Tools

Open defecation field
In the initial stages of an emergency, areas where people can defecate, rather than
where they cannot, should be provided immediately. If there is insufficient time to
construct appropriate facilities this may mean, in extreme circumstance, the setting up
of open defecation areas. These should be located where excreta cannot contaminate
the food chains.
Advantages: Rapid to implement; minimal resources required; minimises indiscriminate
open defecation.
Constraints: Lack of privacy for users; considerable space required; difficult to manage;
considerable potential for cross-contamination of users; better suited to hot and dry
climate.

Trench Latrines
A simple improvement on open defecation fields is to provide trenches in which people
can defecate. This allows users to cover faeces and improves the overall hygiene and
 IRCS First Medical Responder Module 4 22
Water, Sanitation and Hygiene Promotion

convenience of an open defecation system. Shovels may be provided to allow each user
to cover their excreta with soil.
Advantages: Rapid to implement; faeces can be covered.
Constraints: Limited privacy; short life span; considerable space required.

Figure 3.3: Trench Latrine

Pit Latrines
Simple pit latrines are by far the most common technology choice adopted in emergency
situations. This is because they are simple, quick to construct and generally inexpensive.
Advantages: Cheap; quick to construct; no water needed for operation; easily
understood.
Constraints: Unsuitable where water-table is high, soil is too unstable to dig or ground is
very rocky; often odour problems.

Figure 3.4: Pit Latrine

Emergency Response Units (ERU) Mass Sanitation Module (MSM) for 20,000
Beneficiaries
The International Federation of Red Cross and Red Crescent Societies preposition Mass
Sanitation Modules (MSM) to enable timely response during emergencies.
 IRCS First Medical Responder Module 4 23
Water, Sanitation and Hygiene Promotion

Module MSM20 is part of the complete Water and Sanitation ERU which is composed of
3 modules (M15, M40, MSM20).This module provides to up to 20,000 beneficiaries an
integrated response to hygiene and sanitation based on public health needs assessment,
community mobilisation, and the use of rapid and effective sanitation technology and
hygiene promotion.

Figure 3.5: ERU Mass Sanitation Module

Figure 3.6: WatSan Disaster Response Kit

 IRCS First Medical Responder Module 4 24
Water, Sanitation and Hygiene Promotion

Figure 3.7: SanPlat Box Figure 3.8: Rapid Latrine

1.6 Communal or Family?

Family facilities: Usually designed and built by the users (with or without designs, tools
and materials provided by others). They may be used by several families. The latrine
belongs to the family/ies.
Communal facilities: Managed by the community as a shared resource (market, school,
etc.). The facility belongs to the community.

1.7 Handwashing Facilities

Whenever latrine facilities are implemented, handwashing facilities should also be
provided as to encourage positive hygiene behaviour. Providing handwashing facilities is
not always straight forward especially in a large area due to lack of water supply during
emergencies.

Work with your team to chose the right technology (jug, tippy tap, etc) and establish a
system of keeping water available. Always remember to include hygiene promotion with
any latrine construction.

1.8 Operation and Maintenance

When implementing sanitation, training should be provided to ensure that the users are
using the toilets appropriately and cleaning the toilets appropriately. But how do we
encourage people to maintain their toilets?

It is often a challenge to encourage people to maintain their toilets during emergencies,

especially for communal toilets because no one likes to clean other people’s faeces. One
of the many ways to address this issue is to employ someone specifically to clean the
toilets. However, the beneficiaries should first be given the opportunity to organise
maintenance amongst themselves or at least contribute towards the payment of the
toilet cleaner/s.
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Water, Sanitation and Hygiene Promotion

Another factor that would bestow a sense of ownership to the people, which in turn
would encourage maintenance, is to involve the people in design, sitting and
construction of the toilets. Cleaning material as such disinfectants, mops, rags, buckets
and gloves can also be supplemented to assist with the maintenance process.

2. Solid waste management

Solid waste during emergencies can be managed using the following methods:
 Disposal pit – easy to construct and manage, but requires large area.
 Land-filling – normally not available during emergencies, but otherwise presents the
best solution for solid waste management.
 Burning – easy to manage although not environmentally friendly, weather dependent
and may cause health issues over long term.

3. Waste water management (drainage)

Where ever there is a risk of water or wastewater ponding, drainage should be installed to
allow water to flow. This will avoid creating breeding ground mosquitoes. This will also
prevent developing odour issues.

4. Vector control
If eliminating breeding ground is not an option or is not sufficient to control vector problem,
the following two options can be considered to protect the affected population during
emergencies:
1. Personal protection – mosquito nets, incense and insect repellent
2. Insecticide spraying

Figure 3.9: Vector Control

Resource materials for this session:

3. PowerPoint presentation titled ‘3. Sanitation in Emergencies’
 IRCS First Medical Responder Module 4 26
Water, Sanitation and Hygiene Promotion

Session 4 – Hygiene Promotion in Emergency

Objective of this session

1. Understand the basic principles of hygiene promotion.
2. Identify ways of conducting hygiene promotion in an emergency.
3. Identify key hygiene tools used by the RC/RC movement in emergencies.

Session Plan
Timing: 1 hour 40mins
Methods: presentation, group discussions, practical demonstration and role playing

Time Topic Methodology

15 minutes Why do we need hygiene • Ask the participants what they know
promotion? about hygiene promotion? Discuss
some of the methods used and the
effectiveness.
• Explain the principles of hygiene
promotion in an emergency.
10 minutes Selection and distribution of • Discuss the hygiene kits available for
hygiene kits distribution during emergencies.
• Introduce soap and jerry cans as the
only hygiene items provided to
household in emergencies without an
assessment to determine what hygiene
items are more appropriate for that
culture.
15 minutes How do we promote hygiene • Introduce the different avenues which
in emergencies? hygiene promotion can be conducted
in emergencies.
• Discuss the attitude and the qualities of
a hygiene promoter.
• Demonstrate hand washing technique
and discuss key times
60 minutes Hygiene promotion box • Demonstrate the hygiene promotion
box. Remove the picture cards and
explain the 4 activities that can be
conducted using these cards.
• Explain the advantages and constraints
of these activities as a participatory
tool to assess, involve and build trust
with groups to identify hygiene
behaviours and knowledge.
• Divide the group into 4. Hand out:
Pocket Chart, 3 pile sorting, Chain of
contamination, Take 2 children (stress
from PHAST method). Groups to read
 IRCS First Medical Responder Module 4 27
Water, Sanitation and Hygiene Promotion

Time Topic Methodology

instructions and create a role play.
30mins to prepare, 30mins to present.

Tools and Resources required

 Hygiene promotion box x 1
 Facilitator x 1 (Nominally someone experienced in facilitating NDWRT Training
 Flipcharts
 Markers
 Projector

Key Messages
1. The success of hygiene promotion depends on behaviour change.
2. Health messages itself is not a strong motivator for behaviour change. Hence,
hygiene promoters need to listen and be sensitive towards the beneficiaries’ main
concerns before introducing the appropriate tools to encourage behaviour change.
3. Behaviour change is possible as long as we focus on action!

List of Resources
1) Presentation: Module 4 S4_Hygiene Promotion in Emergencies
2) Additional reference material: IFRC HP Box Information Sheet

Content
1 Why do we need hygiene promotion?
There are four main reasons why we should promote hygiene in emergencies:
1.1 Encourage safe hygiene practices – It is important to educate the beneficiaries on
safe water chain in an emergency to prevent spread of diseases in an emergency.
1.2 Ensure optimal use of facilities – Due to lack of training and encouragement, many
beneficiaries have in the past misuse the facilities for example using the latrines as a
storage area. Hygiene promoters also have the role in training beneficiaries on how
to maintain the facilities to ensure sustainable use which is intended to reduce the
risk of disease spread.
1.3 Enable beneficiaries’ participation and accountability – The hygiene promoters will
usually have the most contact with affected communities. Their remit is to listen to
the communities’ viewpoint – whilst this should focus on hygiene – very often they
will need to be sensitive to other community needs and priorities and respond where
possible. Where they are not able to respond they are in a good position to advocate
on behalf of women, men and children or to request the support of another agency.
They can help identify vulnerable groups and support them. They will also be
responsible for monitoring community satisfaction with facilities and/or hygiene kits
and responding to this where possible. It is important to involve the beneficiaries.
1.4 Monitor acceptability and impact on health – This is part of encouraging
participation and greater accountability. Active monitoring should lead to decisions
being made to try and improve or change the situation. At the very least the links
that hygiene promoters create and build with the affected population can ensure
better communication with those responsible for the overall response. Collective
actions/practices/behaviours. Health itself is not measured but the individual or of
 IRCS First Medical Responder Module 4 28
Water, Sanitation and Hygiene Promotion

those affected that can serve as a substitute for impact on health. Links with local
clinics/health personnel can ensure that a timely response is made to an outbreak of
disease or that consistent information is given on the use of ORS or medicines where
required.

2. Selection and distribution of Hygiene kits

Discussions with affected men and women should form the basis of the selection of hygiene
items and while it may not be possible to consult extensively in an acute emergency, there is
always some space for dialogue with the affected population. As Sphere suggests:
‘Existing cultural practices and familiar products should be assessed in specifying the items
supplied. Care should be taken to avoid specifying products that would not be used – due
to lack of familiarity – or that could be misused (e.g. being mistaken for foodstuffs).’

Activities (examples)
• Decide on content and acceptability of items for hygiene kits
• Ensure the optimal use of hygiene items (including insecticide-treated bed nets
where used)
• Water treatment tablets (Aquatabs) should not be taken as a medication

3. How do we do hygiene promotion in emergency?

Hygiene promotion in emergency can be carried out through the following:
• Campaigns
• House to house visits
• PHAST
• Social marketing
It is important to note however that hygiene promotion in emergency is not just about
message dissemination, but also ACTION (behaviour change) and DIALOGUE!!

Interactive methods are time consuming but are often more effective than using the mass
media. (NB. Trade off between reach and effectiveness). They are a good way to understand
the community perspective and can be used as assessment techniques as well as
mobilisation techniques. However, the participatory approach does not always come
naturally to those who are not familiar with these methods and outreach workers will often
need to be trained to use them and then be well supported.

4 Hygiene promotion box

The intended purposes of the box:
 Improve quality of our HP interventions in emergency
 Speeding up HP activities in the first phase of the emergency (first 12 weeks)
 Using 2 approaches- directive approach focusing on mass communication and interactive
approach focusing on community action

Resource materials for this session:

4. PowerPoint Presentation titled ‘4. Hygiene Promotion in Emergencies’