Developing Tools for Impact: Sanitation Behavior Change among Women in Awassa, Ethiopia

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Title:
Developing Tools for Impact: Sanitation Behavior Change among Women in Awassa, Ethiopia
Physical Description:
Project in lieu of thesis
Language:
English
Creator:
Chatfield, Stephenie
Publisher:
University of Florida
Place of Publication:
Gainesville, FL
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Abstract:
This report examines the effect of Sustainable Livelihood Groups on individual women’s sanitation behaviors in Awassa, Ethiopia through the lens of monitoring and evaluation. The evaluation uses the FOAM Framework to examine underlying behavioral determinants of sanitation behaviors, so that the sanitation and hygiene context in the community can be understood. This evaluation examines sanitation issues at the behavioral, group, and institutional level. Primary field data were collected by conducting focus group discussions and administering individual surveys. The purpose of these activities was twofold: to produce data and develop understanding of current sanitation practices and the effect of Sustainable Livelihood Groups on individual women, and also to practically implement a monitoring and evaluation process in order to contribute to the discourse on institutionalizing monitoring and evaluation within development organizations. Key findings that emerge from this evaluation are that the FOAM Framework is a useful tool in designing an evaluation of sanitation behaviors, Sustainable Livelihood Groups are effective in promoting knowledge transfer, social norms, and other sanitation behavior determinants, and that Sustainable Livelihood Group members are more likely to practice proper sanitation behaviors.
General Note:
Sustainable Development Practice (MDP) Program final field practicum report.
General Note:
The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.

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Developing Tools for Impact: Sanitation Behavior Chan ge among Women in Awassa, Ethiopia Meeting w ith focus group participants from a Sustainable Livelihood Group in Awassa Stephenie Chatfield A Field Practicum Report submitted in partial fulfillment of the requirements for a Master of Sustainable Development Practice Degree at the University of Florida, in Gainesville, FL USA March 2013 Supervisory Committee: Dr. Richard Rheingans, Chair Dr. Sarah McKune, Member Mrs. Marit Ostebo, Member

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Table of Contents Acknowledgement s 1 Abstract 3 Introduction 4 Background 5 Ethiopia 5 Water and Sanitation 7 Water is Life International 10 Sustainable Livelihood Groups 12 Monitoring and Evaluation Systems 14 Problem Statement and Objectives 16 Contextual/Conceptual Fr amework 16 Challenges and Objectives 22 Evaluation Methodology 24 FOAM Framework 24 Focus Groups 27 Design 27 Implementation 27 Analysis 28 Surveys 29 Design 29 Implementation 30 Analysis 30 Methodological Considerations 31 Results 32 Analytic Results 3 2 Process Results 50 Conclusions and Recommendations 51 Behavioral 51 Sustainable Livelihood Groups 53 Institutional 55 Loo king Forward 57 References 59 Annex A: Focus Group Discussion Guide 65 Annex B: Preliminary In Country Report to Kale Heywot Church 67 Annex C: Sanitation Beha vior Survey 74 Annex D: Enumerator Training Agenda 82 Annex E: Underlying Behavioral Determinant Levels 83

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Page | 1 Acknowledgements I would first like to thank the individuals and organizations that made my field practicum in Ethiopia possible. My deepest gratitude goes to Water is Life International for their support and willingness to accommoda te me and incorporate my practicum within the organization. Special thanks to Executive Director David Harding for communicating with me on the development and implementation of my practicum and also to Ben and Kelly Taylor for hosting me in Ethiopia, answering so many of my questions, and welcoming me so warmly in their lives. Also, I would like to extend my thanks to Kale Heywot Church and staff for collaborating with me, and also specifically to my translator and friend Wongel for her invaluable help. Lastly I would like to thank the Awassa community and SLGs for sharing their thoughts and lives with me, and truly making my practicum an enjoyable and rewarding experience. Next I would like to thank the University of Florida programs and staff for allowing me this amazing opportunity. Thank you to the Master of Sustainable Development Practice (MDP) Program, Director Dr. Glenn Galloway, and also Ms. Cindy Tarter for all of your support and guidance. Deep thanks also to my colleagues in the MDP program for challenging me a nd also teaching me so much. Special thanks to my committee chair, Dr. Rick Rheingans, without which showed me in regards to development and particularly the water a nd sanitation sector. Also, deep gratitude to my supporting committee members, Dr. Sara h McKune and Marit Ostebo. Finally, I would also like to thank The John D. and Catherine T. MacArthur Foundation for providing funding for my field practicum.

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Page | 2 I also want to use this opportunity to extend deep and sincere gratitude to my personal support system, my friends and family. A huge thank you to my mom Ms. Sue Amole and my step dad Dr. Jack Amole, for your never also thank my sisters, Christy and Kara, for always being here for me and for being such amazing sources far. I also owe deep gratitude to my great friends Shelby, Katy, Taylor, Keri, Ariel, Cami, and Erin (to name a few) for their patience, encouragement, and support. Finally, my biggest thanks goes to my God, Jesus Christ, for blessing me with this experi ence and education, for instilling in me the passion to do this, and allowing me the opportunity to work in His kingdom. He is the living water that I so hope to drink and to share.

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Page | 3 Abstract T his report sanitation behaviors in Awassa, Ethiopia through the lens of monitoring and evaluation. The evaluation uses the FOAM Framework to examine underlying behavioral determinants of san itation behaviors, so that the sanitation and hygiene context in the communit y can be understood. This evaluation examines sanitation issues at the behavioral, group, and institutional level Primary field data were collected by conducting focus group di scussions and administering individual surveys. The purpose of these activities was twofold: to produce data and develop understanding of current sanitation practices and the effect of Sustainable Livelihood Groups on individual women, and also to practi cally implement a monitoring and evaluation process in order to contribute to the discourse on institutionalizing monitoring and evaluation within development organizations. Key findings that emerge from this evaluation are that the FOAM Framework is a us eful tool in designing an evaluation of sanitation behaviors Sustainable Livelihood Groups are effective in promoting knowledge transfer, social norms, and other sanitation behavior determinants, and that Sustainable Livelihood Group members are more like ly to practice proper sanitation behaviors.

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Page | 4 Introduction I conducted my field practicum in Awassa, Ethiopia by implemen ting an evaluation with Water is Life International (WiLi), a n international nongovernmental organization. The purpose of the practicum was to conduct an evaluation of one of areas that focuses on sanitation education and behavior change. WiLi facilitates Sustainable Livelihood Groups (SLGs) as a means of affecting sanitation behavior change in the lives of the pa rticipants, as well as affecting a number of other positive outcomes. The practicum aimed to determine the functioning of SLGs, assess the effect they have on personal sanitation behaviors, and establish a practical monitoring and evaluation system within WiLi for SLGs. In order to understand the complexity of these issues it is imperative to have a full understanding of the background of the issues, and the context of the setting. For this reason, this report includes a background on water and sanitatio n and system approaches to monitoring and evaluation. Also included is a description of the context detailing Ethiopia, the organization WiLi, and the history of SLGs. This background information is meant to set the stage not only for the importance of t his work, but also for the relevance of this work in light of the greater development framework. F ollowing this discussion the specific challenges in the current situation in A wassa and the objectives of the practicum are presented In t he implementation of the practicum focus groups were conducted and surveys administered and so the design, implementation, and analysis of these methodologies are also presented. Results from the behavioral, group, and institutional levels are presented. Then, recommend ations and conclusions are drawn from the

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Page | 5 results The purpose of this report is not only to share this experience and the practicum that I conducted, but also to further the discourse on systems of monitoring and evaluation, and to present new ideas abou t the practical implementation of water and sanitation programs. Background Ethiopia Ethiopia is a large country, with a diverse culture, and a rich historical heritage. Located in the Horn of Africa, Ethiopia is a completely land locked country with a c limate that varies greatly dependent on topography (Purdy, 2007). It is the most mountainous country in Africa and most of the country is dominated by highlands which are separated by the East African Rift Valley (Department of Immigration and Multicultur al Affairs (DIMA, 2006). The majority of the year is dry, with a rainy season running from about June to September depending on the location in country. Ethiopia has experienced at least ten major droughts in the past 40 years, the most recent of which w as in 2011 (DIMA, 2006). Despite being occupied by the Italians for five years, Ethiopia is the only African country that was never colonized by Europeans, a fact which gives much pride to Ethiopians for their national heritage (Michon, 2008). The last e mperor of Ethiopia, Haile Selassie, was overthrown in 1974 by the Derg, a communistic ruling party which held power in Ethiopia until 1991 (The World Bank Group, 2012a). The Derg regime was a highly centralized government that embraced a strong control of the state with firm social and political hierarchies, the legacy of which still underpins Ethiopian society today. The current government, led by the Ethiopian

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Page | 6 poli tical reforms to the government of Ethiopia (The World Bank Group, 2012b). The general elections of 2005 were hoped to lead towards an increase of democracy in Ethiopia. However due to severe pol itical control of the elections rather than a step towards democracy, the elections led to an increase in authoritarianism (Aalen & Tronvoll, 2009). Since that time, new oppressive laws have been instated and local structures have been extended to be used as a means of political contro l and coercion at local levels (Aalen & Tronvoll, 2009). This political climate has created a distrust and paranoia among individuals in Ethiopia towards the government and the ruling party the EPRDF. Ethiopia is the second most populous nation in Sub Sa haran Africa, with a population of more than 84 million people and an annual popula tion growth rate of 2.36 percent (The World Bank Group, 2012b). However, it is challenging to make generalizations about the Ethiopian population because it is extremely di verse ethnically, religiously, and socio economically (DIMA, 2006). Ethiopia embraced Christianity in the fourth century AD, and currently approximately half of the population identifies with the Ethiopian Orthodox Church (DIMA, 2006). Forty percent of t he population identifies with Isla m, and the remaining ten percent either with protestant or animist practices (DIMA, 2006). Although it is one of the fastest growing countries in Sub Saharan Africa, Ethiopia is still one of the poorest and least develope d countries in the world. From 2004 to 2011 Ethiopia experienced a real GDP growth rate of 11 percent, and yet still ranks as the sixth poorest country in the world, based on Gross National Income (GNI) (The World Bank Group, 2012b).

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Page | 7 Socioeconomic factor s reveal the clear dichotomy between growth and development. Average per capita income is less than $390 a year, and over half of the population works in the informal sector (The World Bank Group, 2012b). The average life expectancy is 55 years, and curr ently 46 percent of the population is severely undernourished (Purdy, 2007). Despite the challenges that Ethiopia is presently facing, the country has made significant a significant portions of the national budget to fighting poverty and achieving the MDGs (United Nations Development Programme (UNDP), 2010). Over the past t wo decades Et hiopia has made progress in many key areas such that child mortality has decreased by 50 percent, primary school enrollment rates have increased four fold, and the number of people with access to clean water has doubled (The World Bank Group, 2012b). Ethi opia is on track to reach five of the eight MDGs by 2015, and the challenge now is to sustain the achievements that are already being made, and press forward in the areas where improvement is still needed (UNDP, 2010). Water and Sanitation Access to clean water sources, and proper sanitation behaviors and facilities, are important development factors that are linked to infrastructure, health outcomes, and the burden of poverty. Water and sanitation is incorporated into the MDGs under MDG 7 which strives t o ensure environmental sustainability (UNDP, 2010). The specific target for water and sanitation is to halve, by 2015, the proportion of the population without sustainable access to

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Page | 8 safe drinking water and basic sanitation (UNDP, 2010). According to the Water and Sanitation Program a program administered by the World Bank approximately 2.5 billion people worldwide still do not have access to basic sanitation, 20 percent of which live in Sub Saharan Africa (The Water and Sanitation Program (WSP), 2008). This population remains extremely vulnerable to water borne diseases such as bacterial and protozoal diarrhea, hepatitis A, and typhoid fever (Michon, 2008). Diarrheal disease alone places the greatest health burden on children, and is the number one cau se for under five mortality worldwide (WSP, 2008). Additionally, due to lack of access to basic sanitation and clean water, approximately 3,900 children die every day worldwid e (WSP, 2008). W ater and sanitation are vital areas for human development, and still need much improvement globally. Due to the emphasis on the MDGs, access to clean water has risen dramatically in gains access to clean water every year (T he World Bank Group, 2012a). An improved water likely to be protected from outside contamination, in particular contamination with fecal ters Council on Water (AMCOW), 2010). An improved water source could be a protected spring or dug well, rainwater collection, a public tap, piped water into a dwelling or yard, or other special cases. Tradi tionally Ethiopians rely on surface water (such as ponds) for all their water needs, but now more and more individuals and communities are relying on wells and other improved water sources as their main water source.

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Page | 9 The percent age of the population in Ethiopia that has access to clean water has improv ed from just 14 percent in 1990 to 44 percent in 2010 (Unicef and World Health Orgnization (Unicef/WHO), 2012a ). This is a major achievement, and also indicates that Ethiopia is on track to achieve the MDG of halving the amount of the population without a ccess to clean water by 2015. There is however still a di screpancy in access between rural and urban populations, with only 34 percent of the rural population having access to clean wa ter while 97 percent of the urban population has access (Unicef/WHO, 2012a ). To ensure the health and future development of Ethiopia, it is vitally important that Ethiopia continues to improve access to clean water for the entire population. The current situation and trends for Ethiopia for improved sanitation are not as promising as they are for improved water sources. An improved sanitation facility is defined as improved sanitation facility could be a flush toilet, a connection to a p iped sewer system or septic system, a ventilated improved pit latrine, a pit latrine with a slab, or some other special cases. Fro m a baseline of 3 percent in 1990, there has been an increase in coverage to 21 percent of th e population of Ethiopia in 2010 (Unicef/WHO, 2012b ). The improvements in Ethiopia have come not only from the development of infrastructure and the construction of improved sanitation facilities, but also from efforts made in sanitation education and social marketing (UNDP, 2010). The 34,000 health extension workers to educate and train individuals in regards to health and sanitation (The World Bank Group, 2012a). Consequently, sanitation is not only a matter of access to fa cilities, but also very much dependent on individual beliefs, attitudes, and behaviors

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Page | 10 towards sanitation and hygiene. Despite improvements, Ethiopia is still in drastic need of improved sanitation coverage. Water is Life International The field practicum was conducted in partnership with Water is Life International (WiLi), a non gover nmental organization (NGO) started in 2007 that works exclusively in Ethiop ia mpoverished communiti i, 2009). WiLi is a small organization that is able to achieve a v ast reach due to strong local partnerships and being the in country implementer for many larger aid organizations and NGOs, e.g., Sama Development Emergency Committee (B. Taylor, personal communication, May, 2012). WiLi is committed to bringing immediate, affordable, and sustainable access to safe water to impoverished communities and believes that access to safe water is the first step to individual and community w holeness (About WiL i, 2009). Since 2006 WiLi has drilled over 300 wells serving more than 150,000 people (D. Harding personal communication, January, 2013 ). WiLi has three major programmatic areas, which have specific objectives that lead to drilling, which provides access to improved water sources to communities and individuals. WiLi partners wi th Selam Awassa Water Drilling Works and Sanitation (SAWDWS), an Ethiopian business, to do the well drilling. In this phase of the project WiLi drills the well, installs casing, establishes water use committees, and provides maintenance to the wells. WiL i seeks to address water access and quality issues, and aims to put systems in place that can be sustained

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Page | 11 by ordinary people with the resources they already have (B. Taylor, personal communication, May, 2012). is the formation of Sustainable Livelihood Groups (SLGs). SLGs are based on the model of self help groups, and are generally composed of 15 to 20 people who meet weekly to save their own money together, discuss their lives, and present new ideas to each other (B. Taylor, personal communication, May, 2012). It is members save together is completely their own. WiLi utilizes SLGs as a mechanism to affect positive sanitation behavior change in the lives of individual women. WiLi partners with local institutions, e.g., Kale Heywot Church and Mekone Yesus Church, to initiate and organize SLGs vities that is closely related to the SLGs is the provision of water, sanitation, and hygiene (WASH) education and training to communities and individuals. WiLi also partners with local institutions to provide the WASH education and training. The objecti ve of providing WASH education and tra ining is to give communities knowledge and technical training to be able to adopt good sanitation behaviors. The combination of these three major programmatic areas allows WiLi to provide communities with a holistic w ater and sanitation service so that communities have the resources to fully benefit from access to improved water. WiLi has made a concerted effort to establish a monitoring and evaluation s ystem within their organization so that they can ensure the provi sion of q uality services, and also so they can learn and grow from their past projects. In the past, WiLi has conducted baseline

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Page | 12 surveys in new areas externally through Copernicus Development & Management Consultancy. These evaluative surveys have mostly been conducted for the water d rilling projects. At this time Sustainable Livel ihood Groups SLGs as stated earlier, are generally composed of 15 to 20 people who meet weekly to save their own money together, discuss their lives, and present new ideas to each other (B. Taylor, personal communication, May, 2012). SLGs are composed p rimarily of women who, despite living in extremely close proximity to each other, often did not know each other before joining t he SLG. Key individuals in communities are identified as potential fac ilitators of SLGs and then these individuals are responsi ble for gathering members and starting the group s The groups are not given any money to start; they simply begin saving their own money. The SLGs are completely self organized; the group s establish regulations governing savings and attendance, individua l member s take turns leading weekly meetings and all decisions are decided by discussion and group majority. SLGs are based on the self help group model that originated in India in the 1970s. The self help group model gained international significance specifically after 1976 when Professor Mohammed Yunus of Bangladesh began experimenting with women and micro credit and self help groups (Tolosa, 2007). This m odel started to have an impact in Bangladesh by empowering women through efforts to accomplish poverty eradication. According to Tolosa

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Page | 13 benefit out of mutual help self help groups are that members are from similar socio economic categories, are voluntarily involved, and that the groups utilize a participatory decision making process. Self help groups efficacy, and give women a strong belief in their own agency. SLGs organize around the main function of saving their own money together. Once a SLG accumulates enough group saving s, individual members can then begin taking out small loans from the group for individual use. Savings are collected at weekly meetings, and and social support. Because of the participatory nature of SLGs, weekly group meetings involve extensive discussions not only of group matters, but also of the social support aspect of SLGs seems to be one of the greatest benefits to members of SLGs, and One reason for the effectiveness of SLGs is that they are culturally relevant in Ethiopia because they model similar historically established institutions. There are num erous other indigenous socio economic institutions within Ethiopia that have many of the same characteristics of SLGs, but have a different focus and purpose (Teshome, Zenebe, Metaferia, & Biadgilign, 2012). The most enduring of these is the iddir, a volu ntary burial association in which women save money together to provide for the cost of their burial, and also provide social support to one another (Teshome et al., 2012). The iddir is another social structure that provides women with a critical opportun ity for community development, economic opportunity

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Page | 14 and independence, and social well being (Teshome et al., 2012). Because SLGs utilize a culturally familiar institutional model, these groups are inherently grounded in Ethiopian culture and therefore a m ore viable mechanism with which to introduce water and sanitation education. Monitoring and Evaluation Systems Monitoring and evaluation (M&E) is an important facet of development programs, and is necessary for the development of best practices and genera ting new knowledge and understanding. Within the development field there is a strong emphasis on results generated from M&E, but there is often a lack of understanding about successful M&E systems (The World Bank, 2004). Monitoring systems provide a cont inuous assessment of what is happening within an organization and within programs (World Health Organization (WHO), 2005). Evaluation provides a more systematic approach to determine whether objectives and goals are being met in the best way possible (WHO 2005). A useful and effective M&E system should be simple, responsive to program and community needs, transparent at all levels, and relevant to the objectives of the program (WHO, 2005). There are many reasons for an organization to conduct M&E, some of which are to conduct basic research, to assess the status of a particular variable or variables, to measure effectiveness, and for accounting and certification (Stem, Margoluis, Salafsky, & Brown, 2003). A robust M&E system that is institutionalized wi thin an organization is essential for any organization that wants to effectively reach their objectives, and best serve their beneficiaries. Ultimately, the goal is that a well designed M&E system will function as a feedback loop; taking

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Page | 15 lessons learned f rom projects and programs and utilizing that information in the implementation of future interventions. This transforms organizations into learning organizations which are flexible, open to new opportunities and ideas, and responsive to the reality of the ir work. There has been a recent trend shifting from indicators focused M&E to more comprehensive and sys tematic approaches to M&E that allow for the measurement of impact and outcomes from specific interventions (Stem et al., 2003). Indicators are still necessary and u tilized, however this new approach allows for the incorporation of project cycle management, results based assessment, and learning networks into more development organizations (Stem et al., 2003). M&E is more likely to be effective if the re is an underlying structural model within the organization that explicitly maps the M&E pathway (Newman, Velasco, Martin, & Fantini, 2003). When M&E becomes linked with planning, and these relationships are integrated within the organization, the value of M&E greatly increases and door s are opened to new learning opportunities. A unique set of challenges is presented when attempting to monitor and evaluate water and sanitation programs. Measuring sustainability and scalability of water and sanitation i nterventions is extremely difficult, and there is a long history of failure in this regard. Ned rethink and rework how they operate to focus on long er ). As a leader in the field of M&E for water and sanitation programs, Breslin believes that the key is to focus on outcomes, to use

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Page | 16 emergent technologies, and to use local institutions to encour age participation in M&E (Kanani, 2012 ). Applying a systems and outcome oriented approach to M&E for water and sanitation programs presents many challenges but is vitally important to the growth of development. Problem Statement and Objectives Contextual/Conceptual Framework The Contextual/Conceptual Framework (C/C Framework) presents the specifi c context in which the field practicum was conducted in regards to the practicum activities and layers of consideration in Ethiopia, as we ll as the theoretical con cept of the implementation of the practicum. It is important to und erstand the context in which the field practicum was undertaken, and also to grasp the importance of the overall picture so that the relevance and sig nificance of this work can be fully realiz ed. The image below displays the C/C Fr amework which will be explain ed in detail below.

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Page | 17 In the middle of the fr amework are three squares that represent the three main programmatic activities that WiLi performs: establishing SLGs, providing access to improved water sources by drilling wells, and providing water, sanitation, and hygiene (WASH) education ities in Ethiopia th at sources to impoverished communities i, 2009). All of these activities are implemented through their local partners including SAWDWS, Kale Hey wot and Mekone Yesus Church. T he involvement of the field practicum with WiLi and the evaluation that was conducted focused on one

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Page | 18 rectangles which represent the five livelihood assets from the Sustainable Livelihoods Framework. The Sustainable Livelihoods Approach is an approach born out of Robert Chambers work in the mid 1980s to enhance the efficiency of development processes, and this concept was later developed by the British Department for International Development (DFID) (Kollmair & St. Gamper, 2002). The Sustainable Livelihoods Framework which is illustrated below in Figure 1, is a tool that can be used to understand po verty and to investigate people s livelihoods and the main factors that influence it (Kollmair & St. Gamper, 2002). Figure 1: Sustainable Livelihood Framework The livelihood assets are central to the Sustainable Livelihoods Framework and represent the di fferent strengths that an individual has, which they can leverage for positive livelihood outcomes. Social capital represents the social resources that an individual has, such as networks, relationships, and membership in formal groups (Kollmair & St. Gam per, 2002). Financial capital includes regular flows of money, such as income or remittances, and available stocks such as bank deposits or liquid assets such as jewelry or livestock (Kollmair & St. Gamper, 2002). Physical capital is the basic goods that an individual needs to sustain their livelihood,

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Page | 19 such as transportation, shelter, water, and electricity (Kollmair & St. Gamper, 2002). Human capital is the knowledge, skills, good health, and ability to work that allows a person to pursue their liveliho od objectives (Kollmair & St. Gamper, 2002). Natural capital refers to the natural resources from which livelihoods are derived, such as land, forests, water, and protection against climate change (Kollmair & St. Gamper, 2002). T he livelihood assets have been included in the C/C Framework because it is important to consider the livelihood strategies of the individuals involved with SLGs, and also to consider c rucial in the stage of program planning and design to ensure that activities are meeting the local need, and also building on the available livelihood assets within the community. By building on available livelihood assets, program activities are more lik ely to be internalized within the community and promote full participation and engagement. As we see, to the right of the three main WiLi activities is the outcome of sanitation bu t it is the outcome that was targeted to measure and achi eve Between the activities of WiLi and the desired outcome of personal sanitation behavior change, are the factors that are affected by framework represents the change that is affected. The ovals in the framework represent barriers to individual behavior change, which are lack of social support, false outcome expectations, lack of access to soap, et c. The reason why

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Page | 20 to behavior change by providing the deficit factors. These barriers to behavior change come from the FOAM Framework illustrated in Figur e 2 below, which was created by and is used by the Water and Sanitation Program of the World Bank FOAM stands for Focus, Opportunity, Ability, and Motivation and is a framework that is designed to aid in the design, monitoring, and evaluation of hand was hing behavior change programs (Water and Sanitation Program (WSP), 2010). By identifying specific factors that may constrain, or promote, behavior change we are able to better understand not only whether or not a sanitation behavio r is being adopted, but beyond that why or why not it is adopte d (WSP, 2010). T he FOAM Framework will be discussed more in the discuss ion of the methodologies utilized during the field practicum. Figure 2: The FOAM Framework Within the C/C Framework is a feedback loop that circles from the results of the activities (the sanitation behavior change), back to the institution, to the planning and implementation of programs, and then again back into the program activities. This feedback loo p is representative of the cycl e of M&E M&E findings that are produced from program activities feedback are analyzed so that the findings of the program results can be internalized

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Page | 21 within the institution, and then utilized to create programs that will be more successful and suitable for the context. The power and value of M&E is that result s promote internal learning in an institution, and this information is invaluable in the subsequ ent progr am planning stage. This practicum was attempting to create th is feedback loop within WiLi so that knowledge The institution has been broken down into three combining parts: the culture, the people, and the programs. It i s vitally important that if M&E is to be successful, it must be internalized within each part of the institution. The culture of the institution is composed of the vision and objectives, and the values and practices of the institution. These are the some times established and documented characteristics of the institution as a mechanism for change, but this also is expressed in intangible ways as well. In order for M&E to be valued and internalized by the institution, M&E must be integrated into the instit people of the institution are the staff, and it is important that all the way from the director to the field staff people understand and buy in to the importance of M&E. Through M&E training, and also the influence of the culture of the institution, it is vitally important to foster buy in with everyone involved with the institution. There can be many barriers to this that must be overcome. And then finally, it is important to internalize M&E within program planning and implementati on. Monitoring should be a constant process that is imbedded in program implementation, and results from M&E should always be incorporated into planning. Finally, at the top of the C/C Framework are th e layers of consideration for the field practicum, th e objectives of the practicum, and the analysis. It is important to view the M&E

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Page | 22 process at the different levels of the institution, group, and behaviors. There are interconnections between these three layers which affect the effectiveness of program act ivities, the functioning of SLGs, and ultimately the behaviors and livelihoods of individuals. Challenges and Objectives The field practicum design was directly guided by challenges in the field that were identified by WiLi. This communication ensured that the evaluation would provide valuable information to WiLi and contribute to the discourse on SLGs and personal sanitation behavior change. Throu gh pre planning with WiLi staff major challenges in the field were identified, as well as objectives that could remove those challenges and provide p athways forward. In this way the field practicum can contribute in practical ways to the development process in Ethiopia. One current major challenge is the lack of knowledge about the functioning of SLGs, and their effect on sanitation behavior change. Despite the self help group model bei ng a prevalent model in Ethiopia there is a lack of consensus on the essential elements of these groups and what characteristics best promote group and individual success. Because WiLi establishes SLGs thro ugh local partner organizations there has been shown to be some inconsistency in the groups in regards to the way they are organized, their activities, and the regulations that govern the groups. Also, WiLi has hypothesized that SLGs will be effective in creating sanitation behavior change in the lives of the individual members. However, so far WiLi has not taken any steps to determine or f ormally measure whether this is happening or not. In response to this challenge, the practicum targeted two different objectives.

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Page | 23 Objective 1: Assess the functioning and operation of SLGs to determine essential characteristics for effectiveness This obje ctive examines t he group layer of consideration and raises numerous questions including: What are the essential shared components of SLGs operationally and organizationally? Why is the SLG model powerful and effective? What are the benefits of membershi p to SLG members? Objective 2: Determine the effect of SLGs on individual sanitation behaviors and underlying behavioral determinants This objective regards the behavior layer of consideration and also raises a set of questions including: What barriers prevent individuals from adopting sanitation behaviors? How do SLGs affect barriers to sanitation behavior change? Have SLGs caused sanitation behavior change in the lives of individual members? Another major challenge that was identified by WiLi is tha t they currently do not have an established and consistent monitoring and evaluation system for SLGs. WiLi regularly conducts baseline surveys before the implementation of their drilling projects, and they also conduct monitoring within these but because the formation of SLGs is a new program area for WiLi they have not yet established a monitoring system. This is one reason why WiLi currently lacks information about their SLGs, because they have not been monitoring their progress. The absence of a monit oring system for the SLGs is a need that WiLi self identified and desired to address. This challenge led to the third objective of the practicum:

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Page | 24 Objective 3: Conduct an evaluation that can be utilized by WiLi and used to establish a practical monitoring system This objective examines the institution layer of consideration and also raises numerous questions including: Can the evaluation conducted during the practicum be dupli cated by WiLi? Can the survey designed be used as a pre and post survey for SLG members? What are the barriers within WiLi to establishing a monitoring system? H ow can M&E be institutionalized? The activities conducted during the field practicum directly correspond to addressing these three main objectives, and looking within t he different layers of consideration. As a part of the evaluation both focus groups and surveys were conducted and a detailed discussion of these activities is to follow. Evaluation Methodology FOAM Framework Th e FOAM Framework is an extremely helpful tool in the framing of sanitation and hygiene projects because it deconstructs behavior change into specific barriers and promoters. By doing this practitioners can not only determine whether behaviors are present, but also examine one layer furt her to understand the reason(s) why a behavior is adopted or not. Individual decision making can be affected by a plethora of different variables, wh ether internal or external, which can be related to socio economic status, family dynamics, resource avail ability, and social norms among other things. The FOAM Framework is effective because it

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Page | 25 groups these underlying behavioral determinants into logical categories so that programmatic actions can be appropriately focused. The first determinant category in the FOAM Framework is Opportunity, which asks the question: Does the individual have the chance to perform a behavior? (Water and Sanitation Program (WSP), 2009). Opportunity determinants are often the most external behavi oral determinants and can be com pletely out of the control of the individual. There are three opportunity determinants that are specific to handwashing: access/availability, product attributes, and social norms (WSP, 2010). Access/availability refers to access to soap and water for ha ndwashing, which is especially relevant in a resource poor setting (WSP, 2010). Social norms are the rules that govern how individuals in a group behave, and these can be implicit or explicit. Addressing the issue of access/availability or social norms wo uld require very different interventions, so it is imperative that these determinants be defined and identified within a community. The second behavioral determinant category in the FOAM Framework is Ability, which seeks to answer the question: Is the i ndividual capable of performing the behavior? (WSP, equally as im portant as their actual capacity. There are two ability determinants specific to handwashing with soap which are knowledge and social support (WSP, 2010). Knowledge is acquired through learning and it is important to remember that this is a necessary det erminant for behavior change, but it is not sufficient to ensure it. Social support is the physical and

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Page | 26 emotional assistance given to an individual by those in their community such as family, neighbors, relatives, and peers, and often takes the form of pr actical advice giving, praising/encouraging, and physical assistance with tasks (WSP, 2010). The last behavioral determinant category in the FOAM Framework is Motivation, which asks the question: Does the individual want to perform a behavior? (WSP, 2009 ). Motivation interest (WSP, 2010). This is moderated by opportunity and ability, because even if the motivation is there without the other two determinants adopting a behavior still may not be possible. There are four motivation determinants that relate to handwashing with soap: attitudes and beliefs, expectations, threat, and intention (WSP, 2010). These determinants are related to an present perceptions about the causes of events, expectations are the perceptions of the consequences of handwashing with soap, threat is the perceived risk or danger linked to handwashing with soap, and intention is an perceived plan to enact handwashing with soap (WSP, 2010). The FOAM Framework is a dynamic and practical tool that sheds light on the reasons why an individual washes their hands wit h soap or not. T he FOAM Framework was utilized in the design of the evaluation as a guide for how to organize ques tions and concepts in the focus groups and surveys By identifying specific barriers to behavior change in the determinant categories of opportunity, ability, and motivation, impact pathways are made clear and future intervention s can be focused on areas of particular need. It is hoped that the results found

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Page | 27 here will b e useful in the future design of more effective and targeted interventions for sanitation and hygiene behaviors Focus Groups Design In order to address Objective 1 and Objective 2, focus groups were conducted. The focus group discussion guide includes 13 questions, the first seven of which focus on the functioning and effectiveness of th e SLG which relates to Objective 1. The remaining six questions focus on the indiv norms in the community, which rel ates to Objective 2 (See Annex A ). The focus group discussion guide was designed with the intention of collecting new information on the functioning and organization of the SLGs, which has not previously been documented. Also, it was hoped that the discussion on handwashing would generate a consensus on different behaviors and attitudes regarding handwashing in the community. This information, which would contribute to the evaluation, was also intended to be used in country in the finalization of the questionnaire. The questions in the fo cus group discussion guide regarding handwashing were adapted from a study conducted by PSI in Ethiopia in 2010 regarding household w ater treatment (PSI, 2010 ). Implementation Focus groups were conducted in Awassa in coordination with Kale Heywot Church, which is one of the local institutions which WiLi partners with to organize and establish SLGs.

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Page | 28 Through coordination with Kale Heywot Church staff and SLG facilitators, four different focus group discussions were conducted with four different SLGs. Two o f the groups are located in neighborhoods in the heart of the town of Awassa, while the other two groups are located in Dato, a district of Awassa that is more rural. These groups were randomly selected based on their schedule of availability, and members within each group were also randomly selected by the facilitator to participate in the focus groups. The focus groups ranged in size from nine to fifteen participants, and were almost exclusively comprised of women. Due to the language barrier, all of t he focus groups were conducted in Amharic by a translator. I worked extensively with the translator prior to the focus groups, reviewing the discussion guide and techniques for conducting focus group discussions. She provided invaluable information on th e relevance of the topic to the audience, and also provided input on some rephrasing of the questions. The translat or conducted all the focus groups, which we voice recorded, and I took observation notes during the discussion. W e translated and transcrib ed the voice recording of the discussion on the day of, and the day following the focus groups As a sign of appreciation, all SLGs were given 300 birr (approximately US$16.50) to be Analysis A prelim inary analysis w as conducted in country in order to prepare a cursor y report to provide immediate feedback to Kale Heywot Church and the SLGs that participated ( See Annex B) However, full analysis was not c onducted until fall 2012 used t o analyze focus group data ( Stewart & Shamdasani, 1990 ). A transcript of each of the

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Page | 29 focus groups was printed out, and text from all of the transcripts was coded to the four relevant questions. This was done by reading through the transcript, and highlig hting in different colors the parts of the discussion that related to each question, with the same color correlating to the same question in all of the transcripts. Then, key words, ideas, and themes were extracted from the highlighted text. The extracte d findings were then organized into categories and themes, with the use of the FOAM Framework where applicable. Lastly, representative quotes were selected. Surveys Design In order to addre ss Objective 2 and Objective 3 surveys were administered. The s a nitation behavior survey that was developed includ es a total of 86 questions and includes demogr aphic questions, questions regarding household water sources and use, handwashing behaviors, and also different determinants of h andwashing behavior (See Annex C ). The survey was adapted from a number of establis hed questionnaires and surveys Demographic questions were adapted from the Ethiopia Demographic Health Survey 2011, and the questions regarding household water sources and handwashing behaviors were ad apted from PSI studies conducted in Angola in 2007 and Malawi in 2 008 (PSI, 2007) (PSI, 2008) The section surrounding the FOAM Framework and the different determinants of handwashing behavior was adopted from a study conducted by the Water and Sanitation Program with results from Seneg al and Peru (Water and Sanitation Program, 2012 ).

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Page | 30 The survey was designed and coded before arrival in Ethiopia, and pre tested and edited in country. The survey was pre tested with the interpreter a community member, and also an Ethiopian WiLi staff member. Edits were made to ensure that questions were feasible and culturally relevant The survey was then professionally translated into Amharic. Implementation A team of four experienced survey enumerators was h ired to ad minister the surveys in Amharic in the communities. I conducted a day of training with one of the WiLi staff members who has extensive experience in conducting baseline surveys. During the training we familiarized the enumerators with the survey, present ed an overview of surveying methods and techniques, established clear guidelines for the administration of the survey, and conducted pre testing in a nearby community (See Annex D ). A total of 104 surveys were administered over the course of three days, i ncluding 56 SLG members and 48 non mem bers. SLG members were met through coordination with Kale Heywot Church, and non members were randomly selected in the communities. The majority of participants were women; non members were purposively selected to be mostl y women to match the gender of the SLG members. Survey sampling was conducted in two different areas within Awassa, Community 1 being a more rura l community and Community 2 being more urban in the heart of the town of Awassa. Analysis

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Page | 31 Survey analy sis was conducted using STATA version 12 (StataCorp, 2011) Demographic characteristics were determined by calculating means and standard deviations, and also creating frequency tables. To calculate the levels of the behavioral determinants principal componen t analysis was utilized (Abdi & Williams, 2010) This method allows you to compile a single value that is representative of many contributing components. For example, for each question relating to social support the mean score was calc ulated. These questions were then weight ed for their importance and combined into one value. This value was used to determine a threshold for a high and low score f or social support. In this way hig h and low values were categorized fo r all of the behavi oral determinants using principal componen t analysis. Principal component analysis was also utilized to calculate representative values for the three key sanitation behaviors that are analyzed. Univariate and bivariate comparisons with chi square tests h ave been utilized to compare demographic characteristics to behaviors, behaviors to behavioral determinants, and demographic characteristics to behavioral determinants. Methodological Considerations It is important to consider the unavoidable barriers tha t were present during the implementation of these methodologies, which may have an impact on results drawn from this work. As an evaluation team, and particularly as a foreigner, there were immediate barriers between the local community and evaluators. A t times there was a language barrier, the effect questions that were being asked. It is impossible to know the implications of these barriers, however it is worthw hile to consider. Especially within a political climate that is distrusting and

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Page | 32 wary towards outsiders, it is necessary to consider the effect that this distrust may have on Results Analytic Res ults Objective 1: Assess the functioning and operation of SLGs to determine essential characteristics for effectiveness Objective 1 examines the group layer of consideration for the evaluation conducted of the SLGs. In order to address this objective, q uantitative data from the focus groups were analyzed. The SLGs that participated in the focus groups all displayed robust and engaged participants and appeared to be very successful both on the individual and community level. Across the four different focus groups themes have emerged throu gh analyse s that indicate the essential characteri stics of SLGs a nd why this model is effective. In Figure 3 below, the essential operational and organizational characteristics that emerged during the focus groups are summarized in a Venn diagram. Repeatedly these characteristics were mentioned by individuals in all of the focus groups. Some of these characteristics are clearly operational or organizational, but a few of them fall into both of these categories.

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Page | 33 Some of these characteristics were mentioned more than others and some of them stood out as especially essential to the success of the SLGs. The operational characteristics about open group discussion, group unity and fellowship, and the group concern and support were especially passionate points made by individual s. The voluntary and participatory nature of SLGs is similar to iddirs and other tradition al social groups, and this is one reason why SLGs are so successful. The organization of SLGs is similar to other traditional institutions, and therefore these groups are accepted and able to be more effective. The intangible aspects of the SLGs, such as group support and lov e, are also essential One individual stated: But the most important thing for me is not saving the money, it is the group. I want the people, the fellowship, and to be with them. If some problem happens among us we discuss freely and talk freely, afte r that we solve the problem and go peacefully to

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Page | 34 Organizationa lly within the groups individuals repeatedly came back to the idea of the the individuals within the SLG regarding savings, borrowing, and participation, and were consistently enforced in varying ways by the SLG members. These governing regulations manifested as an important mechanism for the women to avoid conflict with one another, and also as a consistent way to decide amounts of borrowing. It is a very important fact that in all of the SLGs women save the amount of money that they agree to, whether it is the same for everyone or established on an individual basis. These organizational str uctures contribute to the harmony a nd cohesiveness within the SLGs and allow the women to judiciously support one another. One individual stated: regulations to do so in our groups. How can we help each other? According to that There appears to be numerous unique characteristics that have enabled the SLG model to be powerful an d effective in the lives of women in Awassa. Because there are many other similar models to the SLG model that are also based on the self help group model, it is important to note these unique characteristics that may differ from other models. These char acteristics, which participants in the focus groups repeatedly cited as important, include : SLGs and individual members are not given any starting capital decision making Strong r egulations and structure in place

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Page | 35 SLGs create access to credit that was previously unavailable A social structure for women to gather together Members love and care for each other Accountability between members for financial saving Open group discussion Women have roles, responsibilities, and a v oice

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Page | 36 As examples of the success of the SLG model many benefits of membership were cited by individual members. These benefits range in scale from the personal to the community level, and also from the tangible to the intangible. As we can see, these benefits relate to the different capitals from the S ustainable Livelihoods Framework. The benefits mentioned which relate to different capitals, ar e categorized below in Table 1 Table 1: Benefits of Sustainable Livelihood Group Membership Financial Human Social Paid for my child to go to school Learned how to lead others Time for discussion Purchased livestock (cow, calf, sheep, chickens, goat) Learned how to start a business Understanding of the social life Saved my money Learned how to communicate with others Started a busine ss Received trainings Discuss problems and share solutions Improved my house Learned how to share my own ideas Fellowship with other women Traveled to visit my family Learned how to save money Experience tolerance, unity, peace, and love Paid to finish my education and earn my diploma Learned about health and cleanliness Opens opportunities outside of homes Installed a pipe tap in my compound Help each other Built a roadside shop Share new information Bought shoes and clothes for my family Bought medicine for my children Bought food and supplies to celebrate festivals The social capital that is formed within the SLGs is especially powerful and relevant for individual women. The love and support between members of the SLGs was continually what

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Page | 37 individuals cited as the most important and life changing aspects of particip ation in the group. The following quotes illustrate how the social ties between SLG members are valued. ear for me, this face proble ms we visit each other, we discuss with each other. Unless we have love we cannot do that. The most important thing in our group is our strong love for each Objective 2: Determine the effect of SLGs on individual sanitation behaviors and underlyi ng behavioral determinants Objective 2 examines the individual layer of consideration for the evaluation. In order to address this objective, quantitative data from the focus groups and quali tative data from the surveys were analyzed. The dat a from the focus groups portray the perception of SLG members of common barriers to sanitation behavior change present in their community in Awassa. Social norms and social support were barriers that consistently surfaced during focus group discussions. It is a com mon practice in Awas sa to use ash to wash hands rath er than soap, or to simply use water. Not using soap when washing hands is a social norm that is widely accepted in Awassa. Also, it was stated that people do not commonly discuss with each

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Page | 38 other the i ssue of handwashing with soap. There is a lack of discourse and social support on this issue. One individual, in recognition of the need for discussion and support, stated: handwashing. The discussion is necessary, if one person has the knowledge they can tell Another barrier to sanitation behavior change that was identified within focus groups is threat. Many individuals within the community are repor ted to not make a connection between sanitation and health issues, and often do not view poor sanitation as a danger for themselves or their family. An illustrative example of this common perception is explained in this quote: people say that and that saying comes from the habit of not washing hands and not Other barriers that were mentioned in the focus gro ups are access and availability ( specifically that individuals lack the money to buy soap ), knowledge ( especially among more rural populations ) and attitudes and beliefs that soap is not always necessary when handwashing. Data from the survey analysis are very u seful in addressing Objective 2. Data are used to analyze the levels of behavioral determinants present in the part icipatory population, draw out the relationship between different sub groups of the population and the be havioral

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Page | 39 determinants, and identify the r elationship between the behavioral determinants and proxies for different sanitation behaviors. Table 2 below summarizes the characteristics of the participatory population. Table 2: Char acteristics of the Surveyed Population in Awassa, Ethiopia n= Frequency Percent Individual Characteristics Gender of the respondent 105 Male 10 9.5 % Female 95 90.5 % SLG status 105 Member 56 53.3 % Non member 49 46. 7% Marital status 105 Single 19 18.1 % Married/cohabitating 72 68.6 % Divorced/separated 6 5.7 % Widowed 8 7.6 % Education level 105 Illiterate 28 26. 7% Read and write 9 8.6 % Grade 1 6 20 19.1 % Grade 7 8 21 20.0 % Grade 9 10 17 16.2 % Grade 11 12 2 1.9 % Above Grade 12 8 7.6 % WASH Behaviors Main source of drinking water 105 House tap 29 27. 2% Public tap 67 63.8 % Shared tank 5 4.8 % Location of water source 100 In own dwelling 21 21. 0% In own yard/plot 16 16. 0% Elsewhere 63 63. 0%

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Page | 40 Who fetches water in the household 104 Adult woman 62 59.6 % Adult man 2 1.9 % Female child 36 34.6 % Male child 3 2.9 % Treats drinking water 95 31 29.8 % Drinking water treatment method 40 Chemicals in tank 3 7.5 % Chemicals in household container 1 2.5 % Filters 5 12.5 % Stand and settle 26 65.0 % Has handwashing station in home 105 32 30.5 % Type of toilet facility 105 Flush toilet 7 6. 7% VIP latrine 4 3.8 % Pit latrine with covering 40 38.1 % Pit latrine without covering 53 50.5 % No facility/bush/field 1 1.0 % Shares toilet facility with other households 105 84 80. 0% Number of households that share toilet facility 92 2 to 4 households 23 25. 0% 5 to 7 households 30 32.6 % More than 7 households 39 42.4 % The first important relationship that can be analyzed is between different sub groups of the participatory population and the high and low levels of the behavioral determinants. By doing this we can see whether certain groups of the population with simila r characteristics, such as level of education, are associated with high or low levels of the behavioral determinants. A high level of the behavioral determinants would imply a more positi ve situation for the individual and has proven to be correlated with proper sanitation behaviors. Table 3 below shows the percent of different sub groups of the population that presented with

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Page | 41 high levels of each of the six behavior al determinants. Also, Annex E is a table of the avera ge scores for each underlying behavioral determinant which was used to calculate the low and high levels. Table 3: Comparison of Behavioral Determinant Levels among Population Sub Groups Percent (%) High Access/Availability Social Support Social Norms Beliefs & Attitudes Outcome Expectations Threat SLG Member No 21.1 46.9 34.7 27.1 18.4 34.7 Yes 69.6 49.1 61.8 70.9 50. 0* 62. 3 Education Low 35.7 46.4 42. 1 46.4 38.6 33.9 High 66. 7* 50.0 57. 5 55.3 31.3 67.4 Age Young 58. 3 58. 3 55.3 45.7 35.4 56.5 Old 41.3 41.3 51.1 53.2 40.4 43.5 Community 1 36.4 43.6 47.3 36.4 33.9 43. 6 2 65.3 53.1 51.0 66. 7* 36.7 55.3 Statistically significant variables (p<0.05) are marked with an asterisk (*) SLG members differed from non members in several key determinants. They have higher levels of access and availability, social norms, and beliefs and attitudes. Figure 4 below more clearly displays these relationship s

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Page | 42 SLG members are significantly more likely than non members to have high levels of certain behavioral determinants. High levels of behavioral determinants indicate that an individual will be more likely to have proper sanitation behaviors. As we ca n see f rom the data, SLG member s levels of access and availability, threat, outcome expectations, beliefs and attitudes, and social norms are all significantly much higher than levels of non members. The only determinant where there is not a significant differe nce is social support. This result is surprising as it seems that SLGs are a social mechanism that should affect social support. This may suggest that levels of social support within the population are either too high or too low to differentiate between members and non membe rs. It may also be that when it comes to the role of SLGs and sanitation behaviors, the functional activities of sharing knowledge and changing norms is more relevant. Overall, the data display a significant trend that membership in a SLG promotes determinants of sanitation behavior change. 0 20 40 60 80 Access/ Availability Social Support Social Norms Beliefs & Attitudes Outcome Expectations Threat Figure 4: Percent of SLG Members and Non Members with High Behavioral Determinant Levels Non Member SLG Member

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Page | 43 Individuals with a higher level of education are more likely to have high levels of access and availability, social norms, beliefs and attitudes, and threat. As seen in Figure 5 above, the only statistically significant relationship here is that individuals with a higher level of education are more likely to have high levels of access and availabil ity. High levels of access and availability mean that an individual has relatively easy access to soap, clean water, and a place to wash hands within their household. The data does show that individuals with a higher level of education actually have lower levels of outcome expectations. This however is not a surprising relationship. Outcome expectat ions often capture an element of optimism, and it is not surprising that individuals with a higher level of education would display a lower level of optimism (Miguel & Kremer, 2003) The overall trend here, that individuals with a higher level of educatio n also have higher levels of behavioral determinants, is not surprising and is consistent with other studies. The last specific relat ionship is the different levels of behavioral determinants between individuals in Community 1 and Community 2. 0 20 40 60 80 Access/ Availability Social Support Social Norms Beliefs & Attitudes Outcome Expectations Threat Figure 5: Percent of High and Low Education Individuals with High Behavioral Determinants Levels Low Education Level High Education Level

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Page | 44 The tren d in Figure 6 shows that individuals in Community 2 are more likely than individuals in Community 1 to have high leve ls of behavioral determinants. It is interesting to note that based on the survey sampling individuals in a more rural community have consistently lower levels of behavioral determinants than individuals in a more urban community This bivariate analysis does not account for correlation among individual characteristics, so it may be that Commu nity 2 is relatively more educated or less poor than Community 1, which could then drive the associations. The second main use of the survey data was to assess the association between high levels of behavioral determinants and targeted sanitation behaviors This was done by comparing the frequency of three sanitation behaviors among individuals with high and low levels of the behavioral determinants. Table 4 shows these results. Table 4 : Comparison of Behavioral Determinant Levels with Sanitation Behavio rs Percent (%) with behavior 0 20 40 60 80 Access/ Availability Social Support Social Norms Beliefs & Attitudes Outcome Expectations Threat Figure 6: Percent of Individuals in Community 1 and Community 2 with High Behavioral Determinant Levels Community 1 Community 2

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Page | 45 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Social Support Low 20.4 61. 1 46. 2 High 40.0* 42. 0 52. 0 Access Low 17.3* 55. 8 17.7 High 44.2* 48. 1 82.4 Social Norms Low 17.0 66.0* 35.3 High 45.1* 35.3 62.8 Beliefs Low 36.5 40.4 72.6 High 25. 5 60.8 28.0* Outcome Expectations Low 29.4 44.1* 40.3* High 32.4 64.9 66. 7 Threat Low 25.0 53. 9 25.5 High 36. 0 46.0 75.5* Statistically significant variables (p<0.05) are marked with an asterisk (*) In Figure 7 below, each of these relationships is illustrated in a bar graph. Figure 7 : Graphical Representations of Different Behavioral Determinant Levels to Sanitation Behaviors

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Page | 46 0 10 20 30 40 50 60 70 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Social Support for Three Proxies of Individual Sanitation Behaviors Low Social Support High Social Support 0 10 20 30 40 50 60 70 80 90 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Access for Three Proxies of Individual Sanitation Behaviors Low Access High Access 0 10 20 30 40 50 60 70 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Social Norms for Three Proxies of Individual Sanitation Behaviors Low Social Norms High Social Norms

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Page | 47 0 10 20 30 40 50 60 70 80 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Beliefs & Attitudes for Three Proxies of Individual Sanitation Behaviors Low Beliefs & Attitudes High Beliefs & Attitudes 0 10 20 30 40 50 60 70 80 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Outcome Expectations for Three Proxies of Individual Sanitation Behaviors Low Outcome Expectations High Outcome Expectations 0 10 20 30 40 50 60 70 80 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent Levels of Threat for Three Proxies of Individual Sanitation Behaviors Low Threat High Threat

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Page | 48 The relationships among the behavioral determinants and the sanitation behaviors vary in direction and significance. For outcome expectations, there is a statistically significant trend expressed in all of the sanitation behaviors that high levels of outcome expectations promote sanitation behaviors. For most of the relationships between the behavioral determinants and the presence of a handwashing station in the household and that the individual washes hands at critical times, there is a positive correlation. This trend shows that these two behaviors can be predicted by the behavioral determinants. However, for the sanitation behavior proxy of an improved latrine b eing used by the household, this relationship is often r eversed. It is important to consider how different of a behavior this is. Making the change of having a handwashing station in the household or washing hands at critical times does not require much money, physical resources, or investment. However, to c hange the type of latrine used by a household could require extensive resources and time. This is one factor that could contribute to the fact that the behavioral determinants do not correlate as well with the proxy for improved latrine use. The last impo rtant relationship that can be analyzed from the survey data is between the population sub groups and the proxies for specific sanitation behaviors. These relationships are illustrated in Table 5 below. Table 5: Comparison of Sanitation Behaviors among P opulation Sub Groups Percent (%) with the Behavior Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times SLG Member Non Member 26.5 51.0 27.1 Member 33.9 46.4 69.1

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Page | 49 Education Low 24. 6 46.5 37.5 High 37.5 52.1 63.8 Age Young 25. 0 37.5 50. 0 Old 31.9 55.3 52.2 Community 1 23.2 39.3 35.2 2 38. 8 59.2 65.3 Statistically significant variables (p<0.05) are marked with an asterisk (*) Data shows that SLG members are significantly more likely than non members to wash their hands at critical times. Also, individuals with higher levels of education and individuals living in more urban areas are more likely to wash their hands at critical times as w ell. It seems that the proxy used in the survey for hand washing at critical times best captured the relationship between population sub groups and sanitation behaviors. 0 10 20 30 40 50 60 70 80 Has a Handwashing Station in the Household Improved Latrine Used by the Household Individual Washes Hands at Critical Times Percent (%) wth behavior Figure 8: Comparison of Sanitation Behaviors between SLG Members and Non Members Non Member SLG Member

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Page | 50 Despite somewhat higher determinants, SLG members are only slightly more likely t o have a handwashing station in their household and no more likely to have an improved latrine in their household. Both of these sanitation behaviors take more pre thought and pre planning to implement, as opposed to handwashing at critical times, so that could be one reason these two behaviors are not as prevalent as handwashing. Also, it seems that handwashing with soap at critical times is something that is discussed in SLGs and is a common topic in the public health dialogue in the area. There is not as much information and discussion about handwashing stations or improved latrines, so this could be acting as a barrier and explain the discrepancies in results with those two sanitation behaviors. Process Results Objective 3: Conduct an evaluation that can be utilized by Water is Life International and used to establish a practical monitoring system The results for this objective come from the experience during the field practicum of applying the FOAM Framework, conducting an evaluation, and attemp ting to establish a monitoring system of SLGs for WiLi. During the field practicum the FOAM Framework was successfully applied as a guiding structure for the evaluation materials and a nalysis The FOAM Framework directed the design of the survey question s and the focus group discussion guide, and also the comparisons and calculations done during analysis. The use of this framework provided a logical flow to the practicum and analysis, and also was a practical theoretical foundation upon which to draw con clusions. Through the activities that were conducted and the analysis explaine d here a successful evaluation of the structure and functioning of the SLGs was implemented, and the effect that

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Page | 51 was ex amined This is a positive result that has potential to be incorporated in the future by WiLi as they establish a n M&E system. Th e challenge that was faced with the field practicum, which is faced by so many development organizations, is that of sys temat izing the evaluation that was conducted. In order for this evaluation to be duplicated by WiLi there has to be an internal force that prioritizes M&E and is proactive about utilizi ng the M&E system that has been piloted Since leaving the field there has been ongoing com munication with WiLi in regards to evaluation results and possible future projects for SLGs. Conclusions and Recommendations Behavioral Numerous conclusions can be drawn at the behavioral level in regards to sanitation behavior change. Based on the data, s ocial support is at a relatively low level for the majority of the participatory popu lation in Awassa, regardless of SLG member status, education, or any other factor. This indicates that social support is currently one of the greatest barriers to sanitation behavior change in the lives of individuals in Awassa. The survey questions that pertained to social support asked whether the individual had been advised or taught by neighbors or anyone else to wash their hands with soap. We can conclude from this that t he lack of social support in regards to sanitation is due t o the fact that sanitation is currently not a topic that community mem bers discuss or advise each other on Social support will need to be targeted specifically in order to eliminate this barrier to sanitation behavior change.

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Page | 52 Results show that certain sub groups of the population are more likely than other s to have high levels of the behavioral determinants SLG members, more educated individuals, and individuals living in more urban areas are all significantly more likely to have high levels of the behavioral determinants Due to the design of the evaluation causation cannot be determined and it cannot be tested whether behavioral differences are attributable to SLG me mbership or educational level. However, t here is a definite association between sub groups of the population and high levels of behavioral determinants and t hese linkages are valuable indicators of the pathway of progress for sanitation behaviors. The sa me relationships that are displayed between population sub groups and behavioral determinants are evident in the link between population sub groups and behaviors. SLG members, more educated individuals, and individuals living in more urban areas are all si gnificantly more likely than other individuals to wash their hands at critical time s This finding supports the validity of the FOAM Framework, and of these behavioral determinants being accurate indicators of sanitation behaviors We can conclu de from this that targeting these underlyi ng behavioral determin ants for sanitation behaviors may be an effective way of changing personal sanitation behaviors. Based on these conclusions, I would make the following recommendations in order to be the most effective in promoting improved sanitation behaviors in the community: Target improvement in social support in the community by increasing the dialogue on sanitation and hygiene issues particularly through peer relationships

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Page | 53 Focus on providing more sanit ation information and education to older members of the community, and a lso individuals who live in rural areas Provide educational materials and training on water treatment methods (the most common method currently used is to allow the water to stand and settle) Target access and availability issues, particularly in regards to access to soap and the knowledge and materials necessary to have a handwashing station and improved latrine Sustainable Livelihood Groups SLG members are significantly more likely than non members to have high levels of sanitation behavior determinants. From this we know that SLG s promote individual levels of access/availability, social norms, beliefs and attitudes, outcome expectations, and threa t. SLG s do this by providing a unique combination of services including sanitation education and training which can affect knowledge, beliefs and attitudes, and outcome expectations, group fellowship which can affect social norms and social support, and access to loans which can affect access and availability. Discussions during focus groups revealed many benefits of SLG membership to the women involved. Beyond the realm of sanitation issues, SLGs provide benefits to members that affect their social lives and relationships, their family financial situation, and numerous other areas. As a structure, SLGs provide numerous development benefits in the lives of individuals, and also in the surrounding community. From this know that SLGs could potentially have a positive e ffect overall within the community.

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Page | 54 From survey analysis we know that SLG members are significantly more likely to wash their hands at critical times, and we know that SLG s overall are associated with higher levels of determinants of sani tation behavior change SLGs do not seem to have a consistent effect on the likelihood of people have handwashing stations in their household, or for having an improved latrine within the household. Despite the fact that SLGs provide an opportunity for individuals to save money and to therefore have more financial ability, this does not translate to an increase in handwashing stations or improved latrines. SLGs do not currently remove the barrier of access and availability and financial cost, and this p resents an opportunity where SLGs could be leveraged this way in the future. The data show that there is a correlation between SLGs and handwashing behaviors and also higher levels of sanitation behavioral determinants, however further evaluation would hav e to be conducted to draw concrete conclusions of causation. From focus group discussion data we can see that SL Gs promote communication between individuals, which leads to a transfer in knowledge and evolving social norms. It is hoped that the presence of SLGs in the community has a positive effect not only on the lives of the women involved, but also their families, neighbors, and surrounding communities and this evaluation is the first step in verifying this More specifically to this practicum resu lts show that SLGs are a potentially promising avenue for intervention for individual sanitation behavior change and certainly worthy of further evaluation Based on these conclusions, my recommendations in regards to SLGs are:

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Page | 55 Continue monitoring the SLG s so that more conclusions can be drawn and causation determined Due to the strong social nature of SLGs leverage SLGs to target social support issues within the community and use them as a setting for dialogue about sanitation issues Utilize SLG saving mechanisms to support community built latrine projects and the construction of handwashing stations Continue to use SLGs as an avenue to educate and encourage the community about sanitation behaviors Institutional From the experience of the field practicu m we can conclude that the application of the FOAM Framework as a structure for the evaluation was very useful. The FOAM Framework gave structure and consistency to the evaluation activities and methodologies. Also, analyzing behavioral determinants of s a nitation behaviors is useful because it lends another layer of understanding to the development practitioner. By examining different behavioral determinants not only was the presence of behaviors determined, but also w hy they were present or not T his f urther layer of understanding is extremely valuable and much more useful in the process of planning for further inte rventions and is one of the major advantages of using the FOAM Framework. The question of whether this application and evaluation is practi cal is also very important when considering future M&E that WiLi may undertake for SLGs. The results from

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Page | 56 this evaluation have been positive in that an accurate body of knowledge has been generated on a topic that was before not completely understood (tha t is the effect of SLGs on individual sanitation behaviors). In this way we can conclude that this evaluation has been useful not only for WiLi, but also for the knowledge and practices of the greater development field. It is certainly worthwhile for WiL i to continue monitoring SLGs to see the continued effect they have and also to know when new opportunities for program planning or intervention arise. However, the exact methodologies used here may not be the most practical for WiLi to continue using in the future. This evaluation has set forth a useful framework and methodologies that should be utilized by WiLi in the future, but the process can perhaps be simplified in order to maximize efficiency. The survey used here was long in length, and it may b e that a shortened survey, focusing on the FOAM Framework and household sanitation behaviors, may be more practical for repeated use. The combination of utilizing focus group discussions and surveys proved to be quite beneficial during the evaluation as b oth methods lend a different data perspective. These technical considerations are overshadowed by the continuing need of WiLi to establish a consistent monitoring plan of the SLGs. Based on the usefulness and practicality of this evaluation, it can be co ncluded that some modification of this evaluation would be useful to WiLi in the future and should be internalized within the institution. Based on these conclusions, my recommendations in regards to the institution and internalizing M&E within WiLi are: Continue using the FOAM Framework as a guiding structure in M&E of the SLGs

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Page | 57 Continue to track changes in the sanitation behavioral determinants and behaviors, so that stronger conclusions can be drawn over time Utilize this evaluation with some modification for brevity and usability, within WiLi to perform systematic monitoring of SLG s, i ncluding pre and post surveys Provide M&E training to WiLi staff members to ensure a consistent M&E plan Looking Forward Ethiopia is a beautiful country with a rich cultural heritage and what I believe is a promising future. In conversations in villages in the south and on the streets of Awassa, underlying the harsh realities of everyday life there is an undeniable spirit of pr ide and determination that carri es on This spirit is the intangible driving force that will compel can be seen not only in the water and sanitation sector but also in many ot her human developmen t sectors. The Human Development Index (HDI) is a composite measure used widely by development practitioners to assess long term progress in three basic dimensions of human development: a long and healthy life, access to knowledge and a decent standard of living (United Nations Development Programme (UNDP), 2011). 0.363, ranking Ethiopia 174 out of 187 countries (UNDP, 2011). Despite Ethiopia being in the low human development category, we can see that over the years Ethiopia has made strides

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Page | 58 in all aspects of human devel opment, w hich is displayed in the data in Figure 8 below (UNDP 2011). Ethiopia has been steadily improving in all aspects of human development, and these trends are likely to continue into the future. The water and sanitation lessons and advancements that are p resented here fit into this overarching trajectory of development for Ethiopia. As more individuals gain access to clean water, and gain the tools necessary to give their family good health through proper sanitation, so do others gain a longer life, more economic freedom, and the opportunity for their children to attend school. As development practitioners we strive to not only be a part of this life changing improvement in Ethiopia, but also to contribute to the holistic growth and learning of the develo pment process. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 2000 2005 2010 2011 Figure 8: Trends in Ethiopia's HDI components from 2000 2011 Life Expectancy Education GNI per capita HDI

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Page | 59 References Aalen, L. & Tronvoll, K. (2009). The end of democracy? Curtailing political and civil rights in Ethiopia. Review of African Political Economy, 36 (120), 193 207. Abdi, H. & Williams, L. J. (2010). Principal component analysis. Wiley Interdisciplinary Reviews: Computational Statistics, 2( 4), 433 459. African Ministers Council on Water. (2010). Water supply and sanitation in Ethiopia: Turning finance into services for 2015 and beyond. Retrieved from http://www.wsp.org/wsp/sit es/wsp.org/files/publications/CSO Ethiopia.pdf Department of Immigration and Multicultural Affairs. (2006). Ethiopian community profile Commonwealth of Australia Retrieved from http://www.immi.gov.au/living in australia/delivering assistance/government programs/settlement planning/_pdf/community profile ethiopia.pdf Kanani, R. (2012, September 18 th ). Water for people ceo: We need to focus on outcomes, not inputs. Forbes. Retrieved from http://www.forbes.com/s ites/rahimkanani/2012/09/18 / water for people ceo we need to focus on outcomes not inputs/ Kollmair, M., St. Gamper. (2002). The sustainable livelihoods approach. Development Study Group, University of Zurich. Aeschiried, Switzerland.

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Page | 60 Michon, H. (2008). Ethiopia. In Y. Zhang (Ed.), Encyclopedia of global health. (pp. 628 629). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412963855.n429 Miguel, E., & Kremer, M. (2003). Networks, social learning, and technology adoption: The case of deworming drugs in kenya Center for Labor Economics, University of California, Berkeley Newman, J., Velasco, M. A., Martin, L., Fantini, A. M. (2003). A system dynamics approach to monitoring and evaluation at the country level: An application to the evaluation of malaria control programs in Bolivia. The World Bank. Retrieved from http://csdnet.dyson.cornell.edu/papers/newman.pdf PSI. (2007). Angola m aternal and child health trac study evaluating water treatment and hygiene for the prevention of diarrhea and cholera among caregivers of children under five in Luanda Province. Retrieved from http://www.psi.org/sites/default/files/publication_files/ 712 angola_mch.pdf PSI. (2008). Malawi maternal and child health trac study evaluating oral rehydration salts (ors) and hygiene for the prevention of diarrhea and cholera among caregivers of Children under five. Retrieved from http://www.psi.org/sites/d efault/files/publication_files/830

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Page | 61 malawi_trac_mch_ors_smrs.pdf PSI. (2010). Retrieved from http://www.psi.org/sites/default/files/publication_files/Study%20Design%20 %20Ethiopia,%20 Safe%20Water.pdf Purdy, E. (2007). Ethiopia. In P. Robbins (Ed.), Encyclopedia of environment and society. (pp. 613 615). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412953924.n378 StataCorp. 2011. Stata Statistical Software: Release 12 College Station, TX: StataCorp LP. Stem, C., Margoluis, R., Salafsky, N., Brown, M. (2003). A review of monitoring and evaluation approaches and lessons learned in conservation. Wildlife Conservation Society. Retrieved from http://portals.wi.wur.nl/files/docs/ppme/FOSWPCsubmission.pdf Stewart, D. W., & Shamdasani, P. N. (1990). Focus groups: Theory and practice. Washington, DC: Sage Publications, Inc. Teshome, E., Zenebe, M., Metaferia, H., Biadgilign, S. (2012). The role of self help voluntary iddirs (burial societies) in Ethiopia. Community Health, 37, 706 714. doi: 10.1007/s10900 011 9503 2

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Page | 62 The World Bank. (2004). Monitoring & evaluation: Some tools, methods & approaches. Retrieved from http://siteresources.worldbank.org/EXTEVACAPDEV/Resources/ 4585672 1251481378590/MandE_tools_methods_approaches.pdf The World Bank Group. (2012a). Country partnership strategy for the democratic republi c of Ethiopia Ethiopia Country Management Unit. Retrieved from http://siteresources.worldbank.org/INTAFRICA/Resources/257994 1337109990438/Ethiopia_CPS_SECPO_31Aug2012_CLEAN.pdf The World Bank Group. (2012b). Ethiopia overview Retrieved from http ://www.worldbank.org/en/country/ethiopia/overview Tolosa, B. (2007). Assessing the socio economic impact of self help groups: A case to Ethiopian kale heywet church. Addis Ababa University. Retrieved from http://etd.aau.edu.et/dspace/bitstream/123456789/1960/1/Bezabih%20Tolosa.pdf Unicef and World Health Organization. (2012a). Estimates for the use of improved drinking water sources. Joint Monitoring Program. Retrieved from http://www.wssinfo.org/ docum ents links/documents/?tx_displaycontroller[category]=&tx_displaycontroller [year]=&tx_displaycontroller[region]=&tx_displaycontroller[search_word]=ethiopia&tx_ displa ycontroller[type]=country_files

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Page | 63 Unicef and World Health Organization. (2012 b ). Estimates for the use of improved sanitation facilities. Joint Monitoring Program. Retrieved from http://www.wssinfo.org/ documents links/documents/?tx_displaycontroller[category]=&tx_displaycontroller [year]=&tx_displaycontroller[region]=&tx_displayc ontroller[search_word]=ethiopia&tx_ displa ycontroller[type]=country_files United Nations Development Programme. (2011). Sustainability and equity: A better future for all. Retrieved from http://hdrstats.undp.org/images/explanations/ETH.pdf United Nations Development Programme. (2010). Ethiopia: 2010 mdgs report trends and prospects for meeting mdgs by 2015. Retrieved from http://www.et.undp.org/index.php?option=com_mdg&Itemid=152 Water and Sanitation Program. (2008). Medium term strategi c framework on sanitation. Retrieved from www.ehproject.org/PDF/ehkm/wsp san_ strategy .pdf Water and Sanitation Program. (2009). Introducing SaniFOAM: A framework to analyze sanitation behaviors to design effective sanitation programs: Devine, J. Water and Sanitation Program. (2010). Introducing FOAM: A framework to analyze handwashing behaviors to design effective handwashing programs: Coombes, Y., and Devine, J.

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Page | 64 Water and Sanitation Program. (2012). Behavioral determinants of handwashing with soap Among mothers and caretakers: Emergent learning from Senegal and Peru. Retrieved from http://www.wsp.org/sites/wsp.org/files/publications/WSP Behavioral Determinants Handwashing With Soap.pdf World Health Organization. (2005). Sanitation and hygiene promotion: Programming guidance. Retrieved from http://www.who.int/water_sanitation_health/hygiene/sanhygpromo.pdf 2009. About WiLi Retrieved from http://www.waterislifeinternational.com/Water_Is_Life/Home.html

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Page | 65 Annex A: Focus Group Discussion Guide Introduction Good Morning. I would like to thank everyone for attending and participating in our focus group. The goal of this session is to receive feedback and to get your ideas, whether positive or negative, focusing on your Self Help group and also the aspects of your life that involve water and handwashing. Our discussions today will be focused on your lives and experiences, and the realities of your Self Help Group and your personal lives. Your responses will not be us ed in University of Florida field practicum). By participating in this focus group, you are consenting to allowing us to document your discussions. No names will be included in the final report. All comments are appreciated and valuable to the purpose of our study. Directions In the next 1 to 2 hours, we will be taking notes and observing your discussion and recording d we would like everyone to speak as much as possible, as it will help us gain a better understanding of the ideas we are studying. The discussion might end before the 2 hours are up, but the discussion will not go longer than 2 hours. Topics and Question s General Topic 1 : Self Help Group functioning and effectiveness 1. How has participation in your SLG affected your life? 2. How is your SLG organized? Is there a leader? Do you have positions? How do you make decisions? How often do you meet? 3. What does your SLG do in meetings and the community? 4. What have you learned from your SLG? 5. What do you like most about your SLG? 6. If you could change anything about your SLG what would it be? Why? 7. In your SLG have you learned about handwashing with soap or other sanitatio n behaviors? What specifically have you learned?

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Page | 66 General Topic 2: Handwashing with soap 1. How do you know when your hands are dirty? 2. When do you think it is most important to wash your hands (if at all)? Why? 3. How and where do you wash your hands? Source of water, soap, ash, treated water, washing station, in a bucket, in a sink, vigorous rubbing, for how long 4. 5. How common is it for people in your community to wash hands with soap? 6. ome people wash their hands with soap (or at certain times)? Do people not have money or access to soap? Is it too time consuming or impractical? Are people not encour aged to?

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Page | 67 Annex B: Preliminary In Country Report to Kale Heywot Church Preliminary Report on Sustainable Livelihood Groups and Personal Sanitation Behaviors Presented to: Kale Heywot Church Presented by: Stephenie Chatfield of Water is Life International and The University of Florida July 2012

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Page | 68 Introduction Sustainable Livelihood Groups are a common societal structure found in Ethiopia, with a large part of the population (specifically women) participating in these groups. Sustainable Livelihood Groups are seen as a powerful tool for individuals to save money, to build social capital, and to bring change in their own lives. This project was conducted in order to determine the effect that Sustainable Livelihood Group partici pation may have on individual sanitation behaviors, with a specific focus on handwashing with soap. It is known that Sustainable Livelihood Groups can behavi or change remains largely unmeasured. This research was conducted in partnership with Water is Life International and the Kale Heywot Church in Awassa, Ethiopia. Methodology The first phase of the project was to conduct focus group discussions with diffe rent Sustainable Livelihood Groups in the Awassa area. Through coordination with Kale Heywot Church staff and Sustainable Livelihood Group facilitators, four different focus group discussions were conducted with four different Sustainable Livelihood Group s These groups were randomly selected based off of their schedule of availability, and members of each group were also randomly selected. The focus group discussions ranged in size from nine to fifteen participants, and were almost exclusively comprised organization and activities, the benefits that the members received from the group, and also the d iscussions was to generate ideas and develop an understanding of group activities and individual knowledge and behaviors. The discussions were conducted in Amharic by a translator, voice recorded, and later translated into English and transcribed. As a s ign of appreciation, all groups The second phase of the project was to administer surveys to Sustainable Livelihood Group members and non members in the community. A survey team of four expe rienced enumerators was hired to administer the surveys. The survey enumerators participated in a one day training and then went into the field to administer surveys. A total of 105 surveys were completed. Sustainable Livelihood Group members were met w ith through coordination with Kale Heywot Church, and non members were randomly selected in the community. The majority of the participants were women, representing the poorest of the poor in the Awassa area. The survey

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Page | 69 included demographic questions, qu estions about household water sources and use, handwashing behaviors, and also different determinants of handwashing behaviors. A small section on self efficacy was also included. The purpose of the survey was to gather information on water use and handw ashing behaviors, and also to evaluate the effect of Sustainable Livelihood Groups on individual sanitation behaviors. The surveys were administered in Amharic and coded for analysis. Individual participants did not receive any compensation for their par ticipation in the surveys, but Sustainable Livelihood Groups Focus Group Findings Focus group discussions revealed that the reported benefits of Sustainable Livelihood Group membership can be categorized into two broad categories: physical and social. Physical benefits centered on opportunities that were given to the individual once they could borrow money from the group. These are opportunities that have greatly improved individuals lives and would not be available without participation in the Sustainable Livelihood Groups Specific physical benefits mentioned are: Purchased livestock (a cow, a calf, chickens, a goat, sheep) Started a small business Opened a smal l shop to sell items and uniforms Paid back debt Built on my home Paid to visit my family far away Installed a pipe tap in my compound Bought a pair of shoes Bought food for my household B ought clothes for my family Bought a bicycle for my husband Bought medicine for my children Paid my own school fees to earn my diploma The second group of benefits most often mentioned in the focus group discussions was social benefits. These ar e the benefits that are a result of the community building and fellowship characteristics of Sustainable Livelihood Groups Despite living close to one another in the same neighborhood, many of the women did not know each other before the formation of the ir Sustainable Livelihood Group Sustainable Livelihood Groups appear to provide a unique opportunity to gather with other women and discuss life issues, which is not available in any other setting. These social benefits are very powerful and transformat ive. Specific social benefits mentioned are:

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Page | 70 Growth as a group and individuals Able to discuss personal problems with others Help each other with personal issues Openly discuss problems and get solutions Gain my neighbors respect and admiration Better understanding of the social life Learn from an open and supportive environment Build unity and community support The group loves each other Brings personal happiness Have learned how to talk to others and sha re our life Brought together different religions and taught tolerance Have learned how to visit sick people Have learned to speak and share our ideas

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Page | 71 In all of the focus groups, when asked what they liked most about their Sustainable Livelih ood Group all of the groups talked about the love and support that they receive from the other women in their group. They discussed the unity, peace, and encouragement that they have together. In regards to sanitation education, none of the Sustainable L ivelihood Groups had received specific sanitation training or education through their group. One of the groups had heard about handwashing with soap from government extension workers that had visited their community, another group had heard about it from the media, and for the other two groups this was a new idea. However, all of the groups showed a general knowledge of the importance of handwashing with soap at critical times such as after using the toilet and before preparing and eating food. All group s claimed to always wash their hands with soap, but admitted that often soap was not available because of money. Groups also stated that in general in their community people know it is important to wash their hands with soap, but whether they do or not is not known. Survey Findings Of the 105 people surveyed, 56 are Sustainable Livelihood Group members and 48 are not members. The majority of the population are female, 95 of the participants, and this is representative of the majority of Sustainable Livel ihood Group members being female. The average age of the participants is 35 and the average education level is grade 6 or 7. For the Sustainable Livelihood Group members the average years of membership in their Sustainable Livelihood Group is 4 or 5 years. The survey revealed some significant differences in behaviors and characteristics between the Sustainable Livelihood Group members and non members. As shown in the chart below, Sustainable Livelihood Group members are more than twice as likely to treat their water as non members.

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Page | 72 Seventy percent (70%) of the time water that is being treated is for drinking. The most popular reported technique for water treatment is to allow water to stand and settle, accounting for 65% of respondents The other common method is to filter water, but only 12.5% of the population does this. The survey showed that Sustainable Livelihood Group members are more likely to use treated water for drinking, washing their hands, washing food, and for washing ut ensils. Only 31% of the population reported having a handwashing station in their home. And of that population, only 9% of the entire population has a handwashing station with s oap in their home. These relationships are illustrated below. The data gathered for the timing of handwashing are illustrated below. 0 5 10 15 20 25 30 35 SHG Members Non Members Do you treat your water to make it safer? Yes No 69% 22% 9% Do you have a handwashing station in your home? No Yes With Soap Yes Without Soap

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Page | 73 Survey results showed that 99% of the population has the correct knowledge in regards to handwashing with soap behaviors and timing. The main constraint to proper handwashing behaviors revea led by the survey is social norms. There is also a significant difference between the self efficacy of Sustainable Livelihood Group members and non members. Sustainable Livelihood Group efficacy is significantly higher than non mem bers. Recommendations for Kale Heywot Church Introduce sanitation training in the curriculum of Sustainable Livelihood Groups to provide practical training to Sustainable Livelihood Group Members for water treatment, handwashing timing, and handwashing tec hniques Focus sanitation training not on knowledge, but on practical elements Encourage the formation of more Sustainable Livelihood Groups especially in rural areas Encourage Sustainable Livelihood Groups to be active in their neighborhoods to discuss s anitation information and proper behaviors with others 0 10 20 30 40 50 60 70 80 90 When do you wash your hands? Without Soap With Soap

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Page | 74 Annex C: Sanitation Behavior Survey 2012 Sanitation Behavior Survey Individual Questionnaire LOCALITY NAME ___________________________________________________ CLUSTER NUMBER ___________________________________________________ HOUSEHOLD NUMBER ___________________________________________________ REGION ___________________________________________________ SELF HELP GROUP NAME ___________________________________________________ DATE ___________________________________________________ Introduction and Consent Hello. My name is __________________ We are conducting a survey to gather information about Self Help Groups and individual sanitation behavior. We would very much appreciate your participation in this survey. This information will help Kale Heywot Church to better serve this community. The survey usually takes up to 30 minutes to complete. As part of the survey we will first ask some questions about your hou sehold. Whatever information you provide will be kept strictly confidential, and will not be shared with anyone other than members of our team. Participation in this survey is voluntary, and if we come to any question you do not want to answer, just let m e know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in the survey since your views are important. At this time, do you want to ask me anything about the survey? May I begin th e interview now? (If the interviewee consents then continue on to the next page to administer the survey)

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Page | 75 NO. FILTERS RESPONSES CODE SKIP 1 Gender of Respondent Male Female 1 2 2 Age ________ 3 Marital Statu s Single Married/cohabitating Divorced/separated Widowed 1 2 3 4 4 Highest academic level obtained Illiterate Read and write Grade 1 6 Grade 7 8 Grade 9 10 Grade 11 12 Above Grade 12 1 2 3 4 5 6 7 5 How many children under 5 in the household? _________ 6 Are you a member of a Self Help Group? Yes No 1 2 7 If yes, for how many years have you been a member of a Self Help Group? Less than 1 year 1 to 3 years 4 to 5 years 6 to 9 years 10 or more years 1 2 3 4 5 8 What is the main source of drinking water for members of your household? [ Choose only one response, the source used the most ] Bottled water House tap Public tap/standpipe Private tank Shared tank Rain water River Lake Other __________________ 1 2 3 4 5 6 7 8 9 9 What is the main source of water used by your household for other purposes such as cooking and handwashing? [ Choose only one response, the source used the most ] Bottled water House tap Public tap/standpipe Private tank Shared tank Rain water River Lake Other __________________ 1 2 3 4 5 6 7 8 9 10 Where is your water source In own dwelling 1

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Page | 76 located? In own yard/plot Elsewhere 2 3 11 How long does it take roundtrip to collect water? Less than 30 minutes 30 minutes to 1 hour 1 hour to 2 hours More than 2 hours 1 2 3 4 12 Who usually goes to this source to fetch the water for your household? [ Choose only one response ] Adult woman Adult man Female child (under 15 years old) Male child (under 15 years old) Other __________________ 1 2 3 4 5 13 How is the water stored in your house? Verify lid. Well closed means with its own lid or impossibility of dirt getting into the water. [ More than one answer is possible ] Well closed jeri can Badly closed jeri can Well closed bucket Badly closed bucket Well closed bottle Badly closed bottle Well closed pot Badly closed pot Other container __________________ For drinking 1 2 3 4 5 6 7 8 9 For other purposes 1 2 3 4 5 6 7 8 9 14 Do you treat your water to make it safer? Yes No 1 2 15 If yes, for what purposes do you treat water? [ More than one answer is possible ] For drinking For washing hands For washing food For bathing For food preparation Other __________________ 1 2 3 4 5 6 16 How do you treat your household drinking water? [ Choose only one response ] Boil Put chemicals in tank Put chemicals in household container Strain through a cloth Filters Waterguard Let it stand and settle Other __________________ 1 2 3 4 5 6 7 8 *Please answer the following questions by stating whether they happen Never, Sometimes, Usually, or Always Never Sometimes Usually Always 17 In the last 30 days, how often did your family drink treated water? 1 2 3 4 18 In the last 30 days, how often did your family use treated water for washing their hands? 1 3 3 4 19 In the last 30 days, how often did your family use treated water for washing food? 1 2 3 4

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Page | 77 20 In the last 30 days, how often did your family use treated water for washing utensils? 1 2 3 4 21 Do you have a handwashing station in your home? Yes No 1 2 22 If so, what kind of station do you have? Tippytap /Jeri can Tippytap /Jeri can with soap Bucket with dipper Bucket with dipper and soap A sink A sink with soap Other __________________ 1 2 3 4 5 6 7 23 When do you wash your hands? [ More than one answer is possible ] Before eating Before preparing food Before feeding children After using the toilet eces Other __________________ 1 2 3 4 5 6 7 24 When do you use soap to wash your hands? [ More than one answer is possible ] Before eating Before preparing food Before feeding children After using the toilet eces Other __________________ 1 2 3 4 5 6 7 25 The last ten times you prepared food, how many times did you wash your hands with soap and water before preparing the food? 1 2 3 4 5 6 7 8 9 10 26 The last ten times you fed a child, how many times did you wash your hands with soap and water before feeding the child? 1 2 3 4 5 6 7 8 9 10 27 The last ten times you used the toilet, how many times did you wash your hands with soap and water after using the toilet? 1 2 3 4 5 6 7 8 9 10 28 bottom, how many times did you wash your hands with soap and water after cleaning the 1 2 3 4 5 6 7 8 9 10 29 What kind of toilet facility do members of your household usually use? [Choose one response] Flush toilet Ventilated improved pit latrine Pit latrine with covering P it latrine without covering No facility/bush/field Other __________________ 1 2 3 4 5 6

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Page | 78 30 Do you share this toilet facility with other households? Yes No 1 2 31 If so, how many households use this toilet facility? 2 to 4 households 5 to 7 households More than 7 households 1 2 3 32 feces? [Choose one response] Leave in open air Bury Put in the latrine Put in the toilet Use disposable nappies Other __________________ 1 2 3 4 5 6 *Please respond to the following statements whether you completely disagree, disagree, agree, or completely agree Opportunity Access/Availability Completely disagree Disagree Agree Completely agree 33 You know of a place where you can buy soap 1 2 3 4 34 There is always enough water to wash your hands when you need to 1 2 3 4 35 You can buy soap when you decide to do it without asking someone else 1 2 3 4 36 You can always find soap when you need it 1 2 3 4 37 Sometimes you want to wash your hands but soap and water are not available ( ) 1 2 3 4 38 You have a designated place in your house for handwashing 1 2 3 4 39 The price you pay for soap is affordable 1 2 3 4 40 Soap and water are always available in your house to wash hands after going to the toilet 1 2 3 4 41 Soap and water are always available in your house to wash hands before eating 1 2 3 4 Social Norms Completely disagree Disagree Agree Completely agree 42 My neighbors have handwashing stations with soap in their homes 1 2 3 4 43 Most of my friends have handwashing stations with soap in their homes 1 2 3 4 44 My relatives have handwashing stations with soap in their homes 1 2 3 4 45 Most f amilies around me make sure they have products used for washing hands with soap next to the latrine 1 2 3 4 46 Most families around me make sure that they have products for washing hands with soap close to their food preparation area 1 2 3 4

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Page | 79 47 My friends make sure that they have products used for washing hands with soap next to the latrine 1 2 3 4 48 My friends make sure that they have products for washing hands with soap close to their food preparation area 1 2 3 4 Ability Knowledge Yes No 49 It is important to use soap when washing hands 1 2 3 50 Handwashing with soap is an important way of preventing disease 1 2 3 51 It is important to wash my hands with soap after using the toilet 1 2 3 52 It is important to wash my hands with soap before p r eparing food 1 2 3 53 It is important to rub your hands together when washing them 1 2 3 Social Support Completely disagree Disagree Agree Completely agree 54 My neighbors have advised me and my family to wash our hands with soap 1 2 3 4 55 People I know have advised me and my family to wash our hands with soap 1 2 3 4 56 Someone has taught me when to wash my hands 1 2 3 4 57 My friends or family members sometimes give me soap for handwashing 1 2 3 4 58 I have learned about hand washing with soap through a government program or community health worker 1 2 3 4 Motivation Beliefs and Attitudes Completely disagree Disagree Agree Completely agree 59 need to use soap ( ) 1 2 3 4 60 You only need to wash your hands wit h soap if they look or smell dirty ( ) 1 2 3 4 61 Washing hands wastes water in a household that could b e better used for other things ( ) 1 2 3 4 62 know you have not touched anything dirty ( ) 1 2 3 4 63 If you wash your hands many times with water you do not need to use soap ( ) 1 2 3 4 64 Washing your hands with soap before feeding a child is important only if you use your hands to feed them ( ) 1 2 3 4 65 You do not need to wash your hands before eating if you use a fork or spoon to eat ( ) 1 2 3 4

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Page | 80 66 Because foods are cooked there is no point in washing your hands with soap before touching them ( ) 1 2 3 4 67 There is no need to wash your hands with soap before feeding a child with a spoon or fork ( ) 1 2 3 4 68 It is important to wash your hands with soap at certain times 1 2 3 4 Outcome Expectations Completely disagree Disagree Agree Completely agree 69 Washing my hands with soap will prevent my children from getting sick 1 2 3 4 70 Washing my hands with soap after using the toilet will prevent the spread of disease 1 2 3 4 71 Washing my hands with soap will make my food cleaner 1 2 3 4 72 Washing my hands with soap will cause sickness for my family and children ( ) 1 2 3 4 Threat Completely disagree Disagree Agree Completely agree 73 In my household, children are not at risk for diarrhea ( ) 1 2 3 4 74 Children are more apt to get diarrhea than adults if they do not wash their hands with soap 1 2 3 4 75 Children can die from diarrhea 1 2 3 4 76 Children who always have diarrhea will not grow properly 1 2 3 4 Self Efficacy Completely disagree Disagree A gree Completely agree 77 I can always manage to solve difficult problems if I try hard enough 1 2 3 4 78 If someone opposes me, I can find the means and ways to get what I want 1 2 3 4 79 It is easy for me to stick to my aims and accomplish my goals 1 2 3 4 80 I am confident that I could deal efficiently with unexpected events 1 2 3 4 81 Thanks to my resourcefulness, I know how to handle unforeseen situations 1 2 3 4 82 I can solve most problems if I invest the necessary effort 1 2 3 4 83 I can remain calm when facing diffic ult situations because I can rely on my own abilit y 1 2 3 4 84 When I am confronted with a problem, I can usually find several solutions 1 2 3 4 85 If I am in trouble, I can usually think of a solution 1 2 3 4

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Page | 81 86 I can usually handle whatever comes my w ay 1 2 3 4

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Page | 82 Annex D: Enumerator Training Agenda SHG Survey Administration: Enumerator Training Agenda Monday, June 18 th 2012 9:30 9:45 Opening 9:45 10:00 Introduction (Stephenie) Introduce Stephenie and WiLi staff, project goals and objectives, and the schedule 10:00 10:30 Orientation (Teddy) Overview of surveying methods and techniques 10:30 11:00 Coffee and Tea B reak Coffee and tea provided by Selam, snack provided by Stephenie 11:00 11:30 Training (Teddy) Overview of the SHG survey, instructions for survey administration, establish clear understanding of the complete survey 11:30 1:30 Lunch Break 1:30 2:30 P re Testing (Teddy) Conducted in the community, enumerator s to practice survey administration with supervision 2:30 3:00 Assignments and Closing (Teddy) Establish individual assignments for the surveying and plan for the next day

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Page | 83 Annex E: Underlying Behavioral Determinant Levels Table 3: Average Levels of Underlying Behavioral Determinants (Range 1 4) Question Mean Access and Availability AA_1 You know of a place where you can buy soap 1.16 AA_2 There is always enough water to wash your hands when you need to 2.17 AA_3 You can buy soap when you decide to do it without asking someone else 2.95 AA_4 You can always find soap when you need it 3.54 AA_5 The price you pay for soap is affordable 3.58 AA_6 Soap and water are always available in your house to wash hands after going to the toilet 2.48 AA_7 Soap and water are always available in your house to wash hands before eating 2.67 Social Norms Norms_1 My neighbors have handwashing stations with soap in their homes 3.18 Norms_2 Most of my friends have handwashing stations with soap in their homes 3.49 Norms_3 My relatives have handwashing stations with soap in their homes 3.54 Norms_4 Most families around me make sure they have products used for washing hands with soap next to the latrine 2.47 Norms_5 Most families around me make sure that they have products for washing hands with soap close to their food preparation area 2.54 Norms_6 My friends make sure that they have products used for washing hands with soap next to the latrine 2.46 Norms_7 My friends make sure that they have products for washing hands with soap close to their food preparation area 2.46 Social Support SS_1 My neighbors have advised me and my family to wash our hands with soap 1.00 SS_2 People I know have advised me and my family to wash our hands with soap 1.00 SS_3 Someone has taught me when to wash my hands 1.01 SS_4 My friends or family members sometimes give me soap for handwashing 2.36 Beliefs and Attitudes BA_1 ( ) 2.26

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Page | 84 use soap ( ) BA_2 ( ) You only need to wash your hands with soap if they look or smell dirty ( ) 2.63 BA_3 ( ) Washing hands wastes water in a household that could be better used for other things ( ) 3.66 BA_4 ( ) have not touched anything dirty ( ) 1.49 BA_5 ( ) If you wash your hands many times with water you do not need to use soap ( ) 1.45 BA_6 ( ) Washing your hands with soap before feeding a child is important only if you use your hands to feed them ( ) 1.35 BA_7 ( ) You do not need to wash your hands before eating if you use a fork or spoon to eat ( ) 1.45 BA_8 ( ) Because foods are cooked there is no point in washing your hands with soap before touching them ( ) 1.53 BA_9 ( ) There is no need to wash your hands with soap before feeding a child with a spoon or fork ( ) 1.52 Outcome Expectations OE_1 Washing my hands with soap will prevent my children from getting sick 1.56 OE_2 Washing my hands with soap after using the toilet will prevent the spread of disease 1.53 OE_3 Washing my hands with soap will make my food cleaner 3.76 OE_4 Washing my hands with soap will cause sickness for my family and children ( ) 3.90 Threat Threat_1 In my household, children are not at risk for diarrhea ( ) 3.90 Threat_2 Children are more apt to get diarrhea than adults if they do not wash their hands with soap 3.83 Threat_3 Children can die from diarrhea 1.92 Threat_4 Children who always have diarrhea will not grow properly 3.81