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Healthwalk (systematic walkabout)
Structured (spot-check) observations
Gender roles/tasks analysis
Appraisal of the methods and tools
To understand hygiene and sanitation issues fully, it is necessary to explore people's ideas, beliefs and knowledge, and their activities. There are many different ways to collect information on the sociocultural and physical context in which hygiene practices occur. For example, it is not enough to describe existing methods of excrete disposal or people's personal hygiene practices, such as hand-washing, without finding out what physical, social, cultural, or economic constraints might be operating locally to cause people to do what they do. People in the study population can be involved in the investigation, analysis, and interpretation of their own situation. This is important, because they will then have an interest in, and a sense of ownership of the information gathered, and they will perhaps have an interest in making use of the study findings if they are presented in accessible forms.
This chapter describes some of the investigative and analytical tools we have found to be very useful for investigating the context in which hygiene practices occur, and the methods for using those tools. It may be worth noting the distinction made between the terms method and tool. Method refers to the way of doing something while tool refers to the instrument used for doing it. For example, a questionnaire is an instrument for collecting information and different methods can be applied when using it: it can be used by the respondent to fill in the answers to the questions herself or himself (self-reporting method), it can be administered by an interviewer who asks the questions and marks the answers given by the respondent on a precoded sheet (formal method), or it can be used as a guide by an interviewer who asks open-ended questions for the respondent to answer in an unstructured way (informal method). A description of each tool (including materials used apart from notebooks and pens which each member of the study team should have) and the method of using it (set of procedures) is provided. You will find that some tools, such as observation and interview schedules, are used for information gathering while others such as Maps, seasonal calendars and historylines are created during information gathering and are more participatory. These participatory tools have wider uses:
They facilitate feedback of the findings to the study population, thereby ensuring participant checking of the information.
They provide accessible ways of storing/documenting study findings for reference in future investigations or follow-up action.
They can be used for monitoring project activities and changes in hygiene practices.
many more participatory tools that can be used in the
investigation and analysis of hygiene practices. This handbook is
by no means exhaustive of available methods/tools. The
methods/tools described can be adapted and modified to suit
particular situations and are thus flexible. What is important is
that each method and tool that you use is described carefully and
the information obtained is analyzed rigorously. You may also
wish to communicate your experiences with these methods/tools or
adaptations thereof (see Evaluation Sheet at the end of this
handbook). At the end of this Chapter and the next you will find
appraisals of each method/tool described (see Tables 3 and 4).
This will help you choose and combine methods/tools informedly.
This method is an adaptation of transect (a method within Participatory Rural Appraisal, PRA) in which the study team spends one to four hours (depending on distances to be covered) walking across the study site(s) in a meandering fashion. It is essential for the study team, in pairs or triplets (not too many in a group to avoid attracting unnecessary attention), to absorb the atmosphere of the study site as they walk up and down the roads and foot-paths, stopping to greet people of all walks of life. Spontaneous informal conversations and discussions on water and sanitation related topics may be held, especially where people normally gather: for example, at the water source(s), village/town square, or the market place. This may provide opportunities to identify key-informants, individuals who are particularly knowledgeable about issues relevant to your study, for example, handpump attendants, traditional doctors, birth attendants, water committee chairpersons, and so on (see "Key-informant Interviewing" below).
To familiarize yourself with the physical context in which hygiene practices occur. This is often done with specific objectives, such as finding out where the water sources are and to assess levels of visible faecal contamination in the public as well as the domestic environment.
To observe how people behave and interact with each other as they go about their daily routines of fetching water, tilling the land, caring for young children, tending animals, cleaning their homes and courtyards, and so on. This provides some insight into what people do when they are not at meetings, for instance.
A checklist of what to look out for - a spot-check observation schedule - is often used (see the example in "Structured (Spot-Check) Observations" below).
Conduct the healthwalk at dawn and/or dusk. Most of the relevant hygiene practices occur very early in the mornings or in the late afternoon/early evenings. It is unlikely that you will observe many of the relevant activities in the middle of the day. Conduct healthwalks at both times of day if time allows. Be careful to observe local customs and social rules. For example, in predominantly Islamic communities, such as those in rural Afghanistan, it is not acceptable for women to walk about and talk to people they do not know. Members of the study team may, in such cases, be allocated tasks that are suitable/ acceptable for their gender.
Familiarize yourself with the tool before you set out on the healthwalk, and use it discreetly, as a reminder, if you need to refer to it during the healthwalk. Do not wave it around during the heathwalk as it might arouse suspicion among the people you meet.
Look, listen, and learn.
Jot down details of what you observed, and make notes of things that were said during conversations with people you met (see Box 11).
Use this opportunity to meet people who may not normally go to meetings, for example, mothers and/or caretakers of young children. Explain to them the purpose of your visit or stay in the area, and invite l them to participate in your meetings.
Be careful not to make mistakes that may endanger your rapport with the study population (see Box 12).
BOX 11. An Extract of Notes from a Healthwalk
From the Rift Valley town of Meki, Ethiopia
study ream proceeded to the public water standpost where
the attendant/fee-collector had promised to be by 8:30. A
number of women came to retch water and when they saw
that there was no sign of the attendant (a young man
anywhere near the standpost. proceeded to a water vending
place cm the main road - a shop that had a piped water
connection and was selling water at the same price as the
public standpost The study ream observed a young man
buying water with a big barrel which he was going to)
transport using a wheel-barrow. The barrel was about 300
litres capacity and he paid sixty cents for in On
returning to the public standpost, the same children who
had pushed their wheel barrows with a few jerrican water
containers were waiting for the attendant to) come and
open the public standpost. It was almost 9:00 and there
was m) sign of him. The study ream decided to go and look
for him at the WSSA offices...He said that he "had
more important things to do at the WSSA office" that
morning which was why he was late. When the study team
mentioned that they were interested in talking with the
water users about the situation of water supply in Meki
he said dismissively, Inesu yemiawkut neger ale
bilachihu new? "witch roughly translates as.
"So you think they know anything about it, do
you?" The study team noted his arrogance and
uncooperative manner troth towards them and towards the
BOX 12. Examples of Common Mistakes Made on a Healthwalk
A member of the study team opened the door of a latrine in one compound, saw that it was dirty, and turned around immediately, slamming the door behind her. The lady of the house, an expectant mother whose hands were covered in soil as she had just returned from her shamba was visibly embarrassed by this reaction. The lady explained that she had only just returned from working in the gardens and that she had not had time to clean the latrine.
member of the study team arrived in the compound of a
homestead where other members of the team were already
engaged in a conversation with homestead owners. Instead
of allowing the conversation to continue after greeting
them, she immediately started asking her own questions,
some of which had already been asked by the other team
Information Management and Review
At the end of this exercise, you should meet with your study team to discuss your notes and observations. You will find that the combined notes and observations make for a detailed data set on both general and specific issues. The notes will include information which may be clearly relevant or significant as well as trivial detail. Summarize your data, noting any observations that appear intriguing, revealing or relevant, to the questions you aim to address in your study. You may also want to formulate further questions for investigation. It is good practice to keep all your notes until the end of the study although you may be tempted to throw away field notes which appear to be irrelevant to your objectives. It is possible that when you get to the overall analysis stage, you will find an explanation to an intriguing finding hidden in field notes that had been put aside.
Information collected during a healthwalk can thus be used by the study team to:
formulate or redefine questions to be addressed in the study in the light of what has been seen and heard;
identify ways to reach different categories of study participants, such as busy mothers/caretakers of young children, community elders, and leaders, through appropriate communication channels;
interprete findings at the end of your investigations;
make decisions on issues related to project design and implementation.
For example, the example cited in Box 11 had an immediate impact on the project concerned (see Box 13 for the project managers' description of how healthwalk data were used).
BOX 13. An Example of Implementation of Information Gathered During a Healthwalk
Supplied by the Manager of the Project Concerned
"Decision criteria adopted by engineers are, all too often, based on figures utilized for previous projects of a similar nature and tend not to be specific for the actual scheme in question. A fundamental principal of the Twelve Towns Water Supply and Sanitation Study carried out by GIBB in Ethiopia was that the solutions proposed for each town should be entirely appropriate for the local population. While underdesign would result in project objectives not being achieved, overdesign could result in an expensive scheme which is unattractive to potential financing agencies and one which would overload the operation and maintenance capabilities of the local authorities. It Is essential that water is supplied at the locations and quantities required and that it is available at an acceptable and affordable price. Failure could result in the local population resorting to traditional sources which are generally polluted and distant from the town.
order to achieve this target, actual water and sanitation
related hygiene practices were evaluated utilizing
methods outlined in this handbook, together with an
indepth evaluation of the ability of the local population
to pay for water utilized. The end result was a project
which provided the appropriate amount of water at
required locations with a realistic division between the
standard supply categories of house connections, yard
connections, and public fountains. In the case of the
town of Meki, the engineers analysing the existing water
supply system picked up on the problems associated with
the standpost, and determined via computer simulation of
the supply network, that enforcement of proper operator
working hours would increase the volume of water
available to the public by approximately 30%."
Observation is a standard anthropological method for gathering information. It is a relatively unobtrusive and highly effective method that is often combined with other methods, such as interviewing. Observations can be done in a structured way, using a set of preselected things to observe, or in an unstructured manner by noting down everything observed and then classifying the information according to relevant themes. When the study objectives are specific, clearly defined, and the time allowed for the study is limited, as is often the case in assessments of hygiene practices, structured observations are more appropriate than unstructured ones. Spot-check observations are the simplest type of structured observations that can be conducted during a healthwalk, as well as during household visits and when interviewing.
To see where water and sanitation-related facilities are located and to obtain first hand information on hygiene practices in and around these locations.
To find out about hygiene-related practices in and around people's homes.
A structured (often precoded) spot-check observation schedule may be prepared, that consists of a list of relevant things to look for. This should reflect local features and may be pretested during the training period (see Chapter 3). An example which was adapted for different settings and translated into the local languages during the development and testing of this handbook is included (see Worksheet 1). Make your own guide to suit your particular setting, and do not be confined to this example.
Study the structured observation schedule well before conducting the observations. Use the skills you learned during the initial training (see Chapter 3).
Be mentally prepared - concentrate.
Try to be unobtrusive - for example, do not wave your checklist around or draw unnecessary attention to what you are doing.
Look, listen, and learn.
Write down your observations. All additional information to what is listed on the spot-check observation schedule should be included in your written notes with as much relevant detail as possible.
Management, Review, and Use of Information
everyone's observation notes in your study team and sort them by
general themes and specific clusters of hygiene practices.
Prepare a summary and keep it safe for crosschecking against
information obtained by other methods in the final/overall
analysis and inclusion in your study report. Define questions for
further investigation arising from your discussion.
Key-informant interviewing is a standard anthropological method which is widely used in health-related investigations (see Pelto and Pelto, 1978). The term key-informant may be used for anyone who can provide you with detailed information, on the basis of their special expertise or knowledge of a particular issue. For example, a local health worker is the ideal key-informant to talk to you about infections, but not necessarily about other matters concerning water and sanitation. A village leader or village health volunteer could be helpful when discussing community participation projects. Women may be ideal key informants to discuss children's defecation habits, and so on. Who you choose as a key-informant depends on the topic that interests you at the time. The investigator would simply raise a topic for conversation with the respondent, then let the respondent take the lead. If the respondent is highly knowledgeable on the subject raised, she or he can become a key-informant.
Worksheet 1. An Example of a Structured Observation Guide Used During a Healthwalk
1. What are the available water sources?
(d) rain water
(e) seasonal pond
(f) public stand post/tap/fountain
(g) hand-dug well
2. Are the water sources protected? (indicate which ones)
3. How far are water sources from people s homes?
(a) less than 100 meters
(b) 100-500 meters
(c) less than 1 km
(d) 1-2 km
(e) 3-5 km
(f) 6-7 km
(g) more than 8 km
4. What activities take place at or near the water source?
(a) washing water containers
(b) washing clothes
(c) bathing/washing self
(d) watering animals
6. What utensils (and means) are used for fetching water?
7. How is water transported from the source to the home?
8. Is water treated at the source, and if so, how?
(a) by filtering with a piece of cloth
(b) by chlorination
(c) by other means
*9. How is drinking water stored in the home?
*10. How is drinking water handled in the home?
1. Is there evidence of faecal contamination?
(a) along the roads?
(b) along the foot-paths?
(c) near the water source?
(d) in/near the fields/shambas?
(e) outside the houses?
(f) inside the houses?
2. What is the contamination observed?
(a) infants/young children's faeces
(b) adults' faeces
(c) cow dung and/or other animal faeces
3. Did you
see anyone defecating?
(Who? Where? Describe)
4. How many of the houses you visited have latrines?
*5. Where is the latrine located? (indicate reasons why, if relevant)
(a) inside the courtyard
(b) outside the courtyard
*6. Observe the latrine.
(a) Does it have a sound superstructure?
(b) Is the floor safe to stand on?
(c) Does it have a slab?
(d) Is the hole small enough to be safe for children?
(e) Does the latrine provide adequate privacy?
(f) Any other features?
*7. Is the latrine in use?
(a) Is the path leading to it clear?
(b) Is it clean?
(c) Is it reasonably free of smell?
(d) Are there cleansing materials in the vicinity? What are they?
(e) Is there water in the vicinity?
(f) Is there ash in the vicinity?
(g) Any other evidence of use?
*8. How close are hand-washing facilities (water and ash or soap) to the latrine?
(a) next to the latrine
(b) within walking distance
(c) inside the house
* Can also be used during household visits in conjunction with semi-structured interviews.
Key-informant interviewing at the beginning of the study may help you to gain a good overview of the relevant issues. You can then begin to develop question lines for focus group discussions, identify issues to covet in observations, and so on. The subject of an interview may be very broad, such as health, or farming, or family structures in the locality; or it may be more specific - which water sources are best for which purposes, for example. Key-informant interviewing can thus provide valuable information on both specific hygiene practices and on the context in which they are assessed.
Management, Review, and Use of Information
management of key-informant review notes, their review/analysis,
and use is the same as that described in ''Semi-Structured
(Informal) Interviews" in Chapter 6.
This method is an adaptation of PRA's Timeline which is used for gathering time-related information. This method is good for establishing good relations between the study team and the participants, as it instills confidence in local people, particularly community elders. Often, investigators consult community leaders and forget to involve the elders who may be more knowledgeable about the history of their locality. Historyline involves such knowledgeable people (who may include individuals identified as key-informants) in a group discussion and analysis of local history, thereby reinforcing the value of their knowledge.
To investigate local history in general terms, e.g., by learning about local, regional, national, and international events that are considered by local people to be important.
To investigate specific issues related to the management of natural resources such as water, land, and fuel.
This method is good for building rapport as it instills confidence in local people, particularly community elders, by involving them in a way that makes them see that their knowledge counts.
Use locally available materials, such as a stick for sketching a straight line on the ground, and stones or leaves for marking events or names of chiefs on the line, the historyline. The dates or names representing memorable events are marked on the historyline.
Invite local elders to meet with at least two members of the study team for consultation about the history of the area.
Explain to the elders that you are interested to learn about important events that have taken place in the past and may or may not have been written down before. Assure them that your intention is to learn and not to judge, and that you are not going to use the information they provide against them.
Listen and learn.
Encourage every participant to contribute. Ask for further explanation of anything that is not clear to you. Ask for confirmation if you feel unsure whether you have understood what you have been told, or if the information given seems surprising or conflicting.
When the historyline chart and discussion are complete, summarize the results verbally and ask the participants if the information you have presented reflects the discussion correctly, and note their responses. Thank everyone for their contribution and bring the meeting to a close. You may wish to serve refreshments, if available.
Present the historyline chart to a larger group of study participants at another time. For example, you could start your next group discussion by giving feedback on what you have learned about local history using the historyline. This serves to stimulate participants' interest in the study.
Management, Review, and Use of Information
The historyline should be transferred to paper for the study team to discuss. This may be done using a flip chart where the historyline can be drawn, showing the appropriate dates, names, and other captions. A detailed account of what was said at the meeting may be written down separately. See Figure 3 and Box 14 for an example of a historyline constructed in the Dodoma region, Kondoa district of Tanzania. In this example, a historyline was used to investigate why Kwayondu village, which has chronic water shortages, was chosen by the early settlers and the answer was provided almost as soon as the meeting began. Six village elders participated in constructing the historyline which was later presented and verified at a large meeting.
The historyline chart can be used as a reference as well as a monitoring tool in follow-up activities. For example, local community groups may want to keep a copy of it as a record of information that had not been previously documented. It may also serve as a project monitoring tool in a follow-up study. The example in Figure 3 can be used to monitor the progress of the WaterAid-supported water supply project and can be updated at given intervals.
BOX 14. Extract of Notes Taken During the Discussion of a Historyline
From Kwayondu village, Tanzania
According to the wazee, village elders, the place which is now known as Kwayondu village was originally called Yoyo because a long time ago, two men were trying to cross the river in that region and one of them was carried off by the floods and subsequently drowned. Shocked by this event, the surviving man shouted "yoyo!" until people could hear him. One of the elders could remember hearing about this incident and about Yoyo around 1947. It was agreed that 1947 could be the starting point.
In 1948, the colonial government built a cattle trough to prepare the place for settlement.. This cattle trough was receiving water from Kandaga spring [through a gravity scheme]. In 1949, most of the people from Chakwe, a village near Kondoa town, were forcibly moved to Kwayondu. The elders explained that this was not a sudden event. It had been premeditated by the colonial government. Some time before the move, the government had prepared the area for settlement by paying some people to clear the forest as part of a tsetse fly control project and built many tembe huts, made of wattle and swab with flat roofs. The people of Chakwe were then transported by government trucks to the new place and were told "These will be your huts. You will live here," when they reached Kwayondu. The new village was full of mosquitoes, so much so that the people could not sleep inside their huts at night. They slept on the roofs of the tembe. One of the elders recalled that he was a young boy at that time and one night while he was asleep, he fell down from the roof and broke his arm. He showed everyone at the meeting the scar on his arm which had resulted from that fall.
village was named Kwayondu because it had many Baobab
trees with beehives on them. The beehives belonged to a
man called Yondu. Mzee Yondu lived in Bukulu, a
distant village close to the western border of Bereko
Division. When he saw that the area where he kept his
hives was being cleared, he appealed to the colonial
government to spare the Baobab trees. He went to see the
District Commissioner (DC), taking with him some of the
honey from the Baobab trees. The DC agreed to spare the
Baobab trees, and so they stand to this day...
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