Hygiene awareness for rural water supply and sanitation projects

Report No. : 819/1/00




Diarrhoea affects millions of people world wide, having the greatest impact on children, especially in developing countries. Waterborne diseases remain a cause for concern in both developing and developed countries world wide. In developed areas, improvement in wastewater disposal, protection of water sources and treatment of water supplies has greatly reduced the prevalence of waterborne diseases. However, in South Africa, with its mix of developed and developing regions, water-related diseases are increasing, as a result of unstructured urbanisation and rapid population growth.

Hygiene education comprises abroad range of activities aimed at changing attitudes and behaviours, to break the chain of disease transmission associated with inadequate water and sanitation. In the context of rural Africa, the ideal of providing every household individually with safe piped water cannot be achieved, and the art of keeping well -hygiene -assumes added importance.

Hygiene education is an indispensable part of water supply and sanitation projects and ensures improved health and sustainability of a system after the technical experts' assistance has been withdrawn. Hygiene education informs community members about the correct use, storage and disposal of water and general hygiene. Supplying clean drinking water and better methods of excreta-disposal do not automatically reduce disease or improve health.

In South Africa it is essential to understand the attitudes and behaviours of developing communities towards water and sanitation. Most developing communities rely on the government to make sure that their projects are sustainable, but it is necessary for them to contribute themselves towards the sustainability of their projects, as well as the development of an appropriate hygiene education and awareness programmes. It is at community level that real decisions on hygiene education should be made. But communities need information to be able to make decisions reflecting their particular aspirations, desires and needs.


The ultimate aim of this research project is to impact on the general quality of life of rural communities by making them aware of their hygiene situation in order to facilitate a change in behaviour towards a higher level of general and personal hygiene and health.

The objectives of the research as per the original contract were the following:

The above-mentioned objectives changed during the course of the project with the advice and support of the Steering Committee, to better address the needs of the developing communities and the implementing agencies of water supply and sanitation projects. These changes were noted in the minutes of the Steering Committee meetings.

The new objectives of the research project were as follows:

These objectives of the project were addressed successfully. An information gathering tool, called the KAP (knowledge, .attitudes and practices) tool for hygiene, was developed and implemented in the rural areas. A Hygiene Awareness Workshop was developed, based on the information gathered by the KAP tool to address the gaps and needs of rural communities regarding hygiene.

The original objectives of the project were also addressed in the sense that an understand the knowledge, attitudes and practices towards water and sanitation (KAP study) in developing communities, using key informant interviews, focus groups and participatory techniques, were obtained in developing the KAP tool. Based on the findings of the KAP tool, a hygiene education/awareness workshop was developed and piloted nine communities in three different provinces (Northern Province, KwaZulu-Natal and Eastern Cape). The communities selected were split into those that have no improved water supply and sanitation, and those that have some improved intervention. The survey was sensitive to gender issues and targeted women. The piloting of the hygiene awareness workshop was evaluated and a final hygiene awareness package was developed that can be used by government departments, consultants, implementers, NGOs, etc. in supporting water supply and sanitation development and environmental health aspects. The Hygiene Awareness Package is supported by information gathering tools, training manuals and training aids.


The project was, however, hampered by budget constraints resulting in the selection of only three techniques for information gathering. More than three techniques can and should be used to elicit the necessary information.

The budget constraints also affected the number of individuals and households that were interviewed. The project team focused on interviewing focus groups in order to increase the number of respondents. The focus groups consisted of eight to 15 respondents. The discussions lasted two to two and a half hours each, meaning that a maximum of three focus group discussions could be held per day.

Similarly, the interviews with households and individuals took 45 minutes to one hour. The implication was that only six to seven individuals or households could be interviewed per day. The budget allowed one member of the project team to stay in one village for only three days, therefore the coverage of individuals and households is low. However, the total number of respondents interviewed (360), including the focus groups, was sufficient to allow the data to be representative for the purpose of the research and the project.


The data from the research shows that more than half of the population of the communities (60,25%) consisted of people younger than 22 years. It was noted that the river and the standpipe are used often to collect water for other uses than drinking water. Rainwater harvesting (water from gutters) is a major source of drinking water in the rainy season in especially KwaZulu-Natal and the Eastern Cape. Rainwater harvesting is not practised widely in the Northern Province, due to the seasonal nature of the rainfall. More than two-thirds (68,42%) of the respondents indicated that they preferred using plastic jerry cans to collect water. Fifty percent of the respondents stored their water outside the house in 200 litre galvanised or plastic drums that, in 81% of the cases, were uncovered. The other 19% of the respondents stored their drinking water in uncovered containers. Two-thirds of the respondents (66,67%) indicated that they treated the water they collected. However, observation of the activities of the households in regard to drinking water showed that the majority of the households did not treat the water before drinking it. The methods for treatment of water reported by the respondents were boiling, using Jik or alum stone, and filtering. These responses indicate that knowledge regarding the necessity for water treatment does exist, but that it is not practised. The main reason provided for not treating the water was that the respondents did not have enough money to buy Jik or water- treatment tablets. The wastewater was not re-used for vegetable gardening in most of the cases. It was regarded as dirty and not suitable for watering crops and vegetables. Wastewater was, however, used for watering flowers in 18% of the cases.

More than two-thirds of the households (68,75%) in the communities had some form of toilet in the yard. The majority of the toilets (76,92%) were pit toilets. Only 23,08% of the households had Ventilated Improved Pit (VIP) toilets. The responses indicated that people who did not have access to a toilet in their own yards used the veld (20%) or the neighbours' toilets (80%). The reason given for not having a toilet was that the household did not have the money to build one. The majority of the respondents (93, 75%) replied that they cleaned the toilets regularly. However, observation revealed that in the majority of the cases these toilets were in a very bad state and very dirty. The anomaly between the responses and reality indicated that the respondents were aware of the need to clean the toilets, but did not practise it. The majority of the toilets (75%) did not have hand-washing facilities next to it. Of the people who did have such facilities, 50% used soap and water, and 50% used water alone. Only 16.67% of the respondents thought it necessary to wash themselves regularly (at least once daily) in order to stay healthy. The majority (83,33%) did not think it necessary to wash themselves regularly.

Fifty percent of the respondents disposed of kitchen waste by throwing it away in the bush, 43, 75% threw it in a hole and 6,25% burned it when they make a fire. No specific reasons for using these specific sites were provided by the respondents. The waste in a hole or rubbish pit was burnt on a regular basis. The respondents said that when the rubbish pit became too full it was covered with a layer of soil and anew pit was dug next to the old pit. It was observed that most yards consisted of a dwelling, a pit toilet (in some cases), a rubbish pit and the cattle kraal. Domestic animals such as chickens, dogs, cats, goats, geese and pigs were allowed to roam and defecate freely in the yards. This created a huge fly problem.

From the data gathered it was clear that the level of general knowledge regarding hygiene is high in all the communities covered during the research. However, this knowledge is not practised, for a number of reasons. The major reason seems to be the lack of the economic means to ensure a more hygienic life style. The people in the rural areas do not have the money to buy disinfectant, or to build toilets.

A second reason is the lack of sufficient water in the communities. The community members do not have enough water to bath each day, orto provide hand-washing facilities at the few toilets available. The water is fetched quite a distance from the household and is used primarily for drinking and cooking.

A third reason is that sanitation does not seem to be a high priority for the people in the rural areas. Electricity and jobs were articulated as major needs, above sanitation. The people who have toilets also experience problems with social and cultural norms and values; for example, a man and his daughter-in-Iaw are not allowed to use the same toilet.

Another reason for the low level of hygiene in the rural areas is the lack of specific knowledge regarding the cause, transmission and prevention of water-related and faeces- related diseases. The level of knowledge regarding the treatment of these diseases is high, because of their prevalence. This knowledge has been obtained mainly from doctors and nurses at clinics and hospitals when a person was ill. When the respondents were probed about ways to prevent disease, they described treatments. This indicated that the concept of prevention was confused with the concept of treatment. Prevention of disease as such was an unknown concept and could be linked to the low level of awareness of the causes of diseases.

The majority of the respondents (77 I 78% ) said that they did not have a health or sanitation committee in their communities. Only 22,22% indicated that they had a health or sanitation committee in the communities. This response could be attributed to the fact that health and sanitation were seen as household issues ratherthan community issues, such as water supply. Health was also understood to be the responsibility of the doctors and nurses of clinics and hospitals. Two of the communities in the Eastern Cape had community health workers living in the vicinity of the communities where the research was done. These community health workers were active in the communities under their supervision. Observation identified these communities as having a higher standard of hygiene than the communities where there was no active community health worker. The lack of institutional capacity to manage health and hygiene in the communities contributed to the low level of hygiene awareness in the communities.

More than half of the respondents (52,63%) did not know whether an environmental health officer (EHO) was active in their community or not. A third of the respondents (31 ,58%) indicated that an EHO was not available for their communities, and 15,79% said that one was available. Further investigation by the research team determined that, according to the respondents, EHOs were active in KwaZulu-Natal, less active in areas in the Eastern Cape, but not at all active in the Northern Province. The majority of the respondents (72,22%) indicated that they felt that training or attending a workshop on hygiene was necessary in their communities. Only 5,56% of the respondents felt that training or attending a workshop on hygiene was not necessary in their communities. A number of respondents (22,22%) did not reply to the question. The respondents who replied to the question indicated that they would like to learn more about the following:


There are ways in which communities can change their practices as far as health and hygiene related to water and sanitation are concerned. That should be the message communicated by any programme of hygiene education. Hygiene education informs community members about how to collect, store, use, and dispose of wastewater in hygienic ways. Emphasis should be placed on the use of clean water for feeding infants and general food preparation, bathing practices and domestic cleanliness. Supplying clean drinking water, increased amounts of water and methods of excreta-disposal does not automatically reduce diseases or improve health. Hygiene education is essential to even begin to achieve such an outcome.

The research team was of the opinion that the development and implementation of a workshop reinforcing the general concept of hygiene, and the cause, transmission and prevention of water-related and faeces-related disease. The workshop should also include action planning by the community members to improve the hygiene in their community with the resources available to them. The workshop was developed, piloted and revised and it is foreseen that it will have a very positive impact on the quality of life of communities.

The research team recommends the following as a possible strategy forthe implementation and improvement of basic health and hygiene in the rural communities, based on the findings of the project:

A strategy proposed to implement the above recommendations might have the following elements:

At this stage the project team can only recommend that the key stakeholders should be invited to a workshop to decide on a strategy for the implementation of the research output. Future developments will depend on the acceptance of the Hygiene Awareness Package by the Department of Health and Department of Water Affairs and Forestry.


The project highlighted areas that need further research, and these are the following: .


This report forms the first report in a set of three documents prepared for project K5/819: Hygiene education to support water supply and sanitation interventions in developing communities. The full set of documents comprises the following:

  1. Hygiene awareness for rural water supply and sanitation projects.
  2. The KAP tool for Hygiene: A manual on knowledge, attitude and practices study for Hygiene Awareness in the rural areas of South Africa (TT 144/00).
  3. Hygiene Awareness Workshop (TT 145/00).