DIARRHOEA, WATER AND SANITATION

(Final Report)

NEPAL MULTIPLE INDICATOR SURVEILLANCE

Third Cycle: February - April 1996

(A focus group discussion in one of the 144 NMIS clusters:

Gadagamba Ward No 5, Kachanari VDC Siraha District)

His Majesty's Government/Nepal-National Planning Commission

Secretariat, Kathmandu

In Collaboration with UNICEF-Nepal

June 1997
 NEPAL MULTIPLE INDICATOR SURVEILLANCE

CYCLE 3: DIARRHOEA, WATER AND SANITATION

FINAL REPORT MARCH 1997

HMG NEPAL, NATIONAL PLANNING COMMISSION

NMIS Report Series, number 3

 EXECUTIVE SUMMARY

Childhood diarrhoea is a major cause of illness and BASIC INDICATORS

death in Nepal. It is very strongly related to the
adequacy of supply of clean water, hygiene practices Figure 1. Summary of NPA goals3 and indicators
and sanitation provision. The Nepal Multiple Indicator from NMIS cycle 3
Surveillance scheme, which began in 19941,2, provides
a framework to study the incidence and severity of
diarrhoea in children and the risk factors associated,
particularly water supply and sanitation arrangements.

This can guide interventions with water and sanitation

at household, community, district and national level,
permitting bench-marking of impact through changing
diarrhoea rates. There are several types of action, some
involving high investment hardware, others requiring
changes of hygiene practice at household level. Not all
of these have the same impact, nor do they all work at
the same time. This cycle provides the strategic
information for planning water, sanitation and hygiene
interventions.
Incidence of diarrhoea
Nepal’s National Plan of Action (NPA) for Children
and Development for the 1990's3 sets goals related to 18% of children under 5 years old had diarrhoea in
childhood diarrhoea mortality, knowledge and use of the last two weeks.
oral rehydration therapy (ORT), water supply and
latrine coverage. The indicators from this cycle of the
NMIS can be compared with the goals in the NPA. The The incidence of diarrhoea is highest among children
goals are shown in Table 2 (p.2). The comparison is aged 7-18 months and slightly higher in boys. The
summarised in Figure 1. small difference between boys and girls is nearly all in
those aged 13-24 months.
METHODS
Data collection and data entry for this third cycle of the Duration, severity and management of diarrhoea
Nepal Multiple Indicator Surveillance (NMIS) took Blood in the stool (an indicator of severity) occurs in
place between February and July 1996. A total of 144 19% of the episodes of diarrhoea reported here. Blood
communities in 37 Districts throughout Nepal were in the stool is more likely with long duration diarrhoea.
visited and information was gathered using a household
questionnaire, key informant interviews, observation
report and focus group discussions. This cycle covered Just under half (43%) of episodes of diarrhoea last
the same communities as were included in NMIS 3 days or less.
Cycles I and II. The NMIS applies Sentinel Community
Surveillance (SCS), a community-based data collection
and management system which aims to produce data in Nearly half of households are aware that children with
a form to facilitate planning at local and national level. diarrhoea should be given extra fluids. But in these
same communities, not even half of the children with
The study base diarrhoea are given fluids (47%) and only a quarter are
‘ 17,227 households given extra fluids. They are often given less food than
‘ 99,265 people normal, in effect causing acute malnutrition which
‘ 13,338 children under 5 years old reduces the recovery of the child from diarrhoea.
‘ 144 key informants
‘ 144 focus groups of mothers

i
 Only one fifth (20%) of children with diarrhoea are
given both extra fluids and continued feeding.
The correct use of ORT (20%), defined as giving extra
fluids and continued feeding, is approaching the 1996
goal of 25% in the Nepal National Plan of Action.
One third (35%) of children are given Jeevan Jal
during diarrhoea (67% of those given any fluids).
The most common error in descriptions of Jeevan Jal
preparation was in giving incorrect amounts of fluid
and powder to be mixed together.
Only a quarter of households give a correct
description of how to prepare Jeevan Jal.
A large proportion of children with diarrhoea are
referred for medical care; if there is blood in the
diarrhoea nearly two thirds are referred while nearly
half are referred even with short duration diarrhoea
with no blood in the stool.
The main sources of household information about
management of diarrhoea are doctors and other health
workers (31%), neighbours or friends (24%) and ‘own
experience’ (24%).
Knowledge about causes of diarrhoea
Only one in ten respondents thought diarrhoea might be
related to food (12%). Diarrhoea is commonly believed
to be due to hot or cold weather (39% of households),
to eating excess food (14%) or to teething (10%).
Focus groups of mothers expressed similar beliefs
about the causes of diarrhoea but more commonly
(18%) mentioned mothers’ lack of time to care for
children as a contributory cause.
Water access and quality
The commonest sources of water are a handpump
(36%), tap/pipe (34%) or well/kuwa (14%).
Households report little difference in water source
between wet and dry seasons.
Access to 'safe' water (defined as water from tap, pipe,
handpump, borehole, spring) within 10 minutes is used
here as the measure of 'access to safe water within a
reasonable distance' (the indicator for water supply in
the National Plan of Action goals).
ii
In the dry season, 44% of households in Nepal
have access to ‘safe’ water within 10 minutes.
Access to 'safe' water (44%) is below the 1996 NPA
goal of 53% nationally, mainly because of low access
in rural areas. The indicator used here is an
approximation to that used by the HMG Government
Department of Water Supply and Sewerage. The
definition of 'safe' water is quite a generous one; not
everyone would agree that piped water, for example, is
safe to drink in all parts of the country. There is still a
long way to go to reach the final goal of universal
access to safe water.
Nearly half of households (41%) cover their water
container and nearly all (90%) throw away old water
and wash out the container before putting in new water.
Very few (6%) households treat their drinking water in
any way. About three quarters of households think the
quality of their water is good, but only half those
getting water from a river, well or kuwa think the
quality is good. Households complain about difficulty
of access to sufficient water (55%) and poor quality of
water (25%).
Latrine coverage and excreta
Household coverage with latrines is 15%
nationally: 12% in rural areas and 63% in urban
areas.
Access to ‘sanitary means of excreta disposal' for
which goals are set in the NPA, is taken as coverage
with latrines. The national latrine coverage (15%)
meets the NPA goal of 16% for 1996. The urban
coverage (63%) more than meets the NPA goal of 50%
and the rural coverage is the same as the 12% goal.
The weighting process means the high urban coverage
does not contribute very much to the national figure.
Latrine coverage may not be synonymous with sanitary
means of excreta disposal if latrines are poorly built
and badly maintained. In this survey, the presence of a
latrine does not reduce the risk of childhood diarrhoea.
Perhaps there is some truth in the perception by
households and communities that latrines are often
unsanitary; many prefer to go into the surrounding area
to defecate.
Many householders (66%) do not perceive the need for
latrines. Focus groups express problems with building
latrines and a perception that they are smelly and a
source of infection.
If there is a latrine, in nearly all households (98%) the
adults use it and in most households (80%) the children
use it.
About a third of households smear their walls and
floors with cattle excreta and mud. Cattle excreta are
used more than the excreta of other animals for all
purposes. High proportions of households believe that
cattle excreta are less hazardous than human excreta
and human baby excreta are less hazardous than adult
human excreta.
Literacy
In 47% of households, the household head is literate.
Among mothers of children under 5 years, only one in
five (21%) is literate.
ACTION ANALYSIS
This section analyses the relations between water,
sanitation, hygiene and diarrhoea with a view to
identifying the impact of possible actions aimed at
reducing the occurrence and severity of diarrhoea.
Diarrhoea incidence
The potential effects of water supply, hygiene practices,
sanitation and maternal literacy on the risk of childhood
diarrhoea were considered separately and in
combination. The results of this analysis are
summarised in Table 1.
‘ Water source. A child in a house with an
‘unsafe’ water supply has nearly 50% more diarrhoea
risk compared with a child in a house with a 'safe'
water supply (tap, pipe, handpump, borehole, spring).
This gap is not explained by sanitation or hygiene
practices.
The implication for childhood diarrhoea of a massive
change in water availability is modest. Universal
provision of water presently defined as ‘safe’ (pipe,
tap, handpump, borehole, spring) could be expected to
reduce the two week incidence of diarrhoea in children
from 20% to 16% (Risk Difference 4%, Table 1). This
relatively modest potential effect raises questions about
the quality of water from these ‘safe’ sources. Most of
the population (67%) already get their water from these
‘safe’ sources, although only 44% have access to them
within 10 minutes.
‘ Treatment of drinking water. A child in a
house that does not treat drinking water has nearly one
and a half times the diarrhoea risk of a child in a house
that does. This effect is not altered when other
variables are taken into account but the benefit if water
treatment is more marked when the water source is
iii
’safe’. The Risk Difference between treated and
untreated water is 4% (13% v 17%).
This implies that water treatment in the home,
including crude methods such as simple filtration, can
reduce the risk of diarrhoea in individual children by
one and a half times (Table 1). If all households
treated water, even by crude means, the rate of
diarrhoea in children could be reduced by 4%.
Analysis of interaction suggests this would be more
effective if combined with provision of ‘safe’ water.
Most households cannot afford to boil the water and
other methods used are less effective. Cheap, effective
methods of home water treatment are needed.
‘ Water container. The risk of diarrhoea in
children in this sample is little affected by covering the
water container and the small benefit noted could well
be due to chance. This could indicate that the water is
contaminated before it gets into the container. The
implication for action is that, before investing in
communication strategies to persuade people to cover
water containers, the quality of the water should be
dealt with.
‘ Latrines. There is a big difference between
owning a latrine and adults using the latrine. Overall,
the risk of childhood diarrhoea in this sample is not
affected by the presence of a latrine. Among children
of literate mothers, there is slightly lower risk of
diarrhoea if the house has a latrine. A child in a house
where the adults use the latrine has only half the
diarrhoea risk of a child from a house where they do
not.
Programmes of latrine provision need to emphasize
education about use. At present many households
perceive latrines as irrelevant or even harmful,
contaminating the environment and concentrating
infection risk. There is no detectable benefit of latrines
in reducing diarrhoea risk in this study.
Table 1. Effects of different variables on the rate of diarrhoea in children under 5 years old
Action Individual benefit % reduction in
(odds ratio) diarrhoea rate
(risk difference)
‘Safe’ water 1.3 4%
supply
Treatment of 1.4 4%
water
Literacy of 1.4 4%
mothers
(1) % of the population who do not have the intervention now; eg 23% do not have water from a ‘safe’ source. In the
case of maternal literacy, 79% of children have an illiterate mother.
Diarrhoea severity
Reducing severity (duration) of diarrhoea can reduce
the mortality and long-term morbidity. Key areas for
intervention here are maternal literacy, practices of
giving fluids and food during episodes of diarrhoea,
and practices of seeking medical help for children with
diarrhoea.
‘ Timing of fluids. Among children given
fluids during diarrhoea, the timing of fluids is all
important. A child given fluids on the first day of
illness has less than one half the risk of long duration
diarrhoea compared with a child not given fluids on the
first day. This effect is not explained by other actions,
like medical treatment or feeding during the episode.
‘ Jeevan Jal. A child given Jeevan Jal as part
of the fluid regime has only three quarters the risk of
long duration diarrhoea compared with a child not
given Jeevan Jal. This effect is not explained by other
aspects of management of diarrhoea.
Literacy of mothers
Literacy of mothers is a protective factor against
childhood diarrhoea. A child with an illiterate mother
has nearly one and a half times the diarrhoea risk of a
child with a literate mother. The effect of mother’s
literacy is not altered when water and sanitation is
taken into account, but the benefit of mother’s literacy
is more marked when there is a latrine. This fits with
the idea that literate mothers instill better hygiene
practices into the household.
Provision of adult literacy classes for all mothers of
young children could reduce the incidence of childhood
diarrhoea from 18% to 14% (Table 1). It is almost
certainly not the literacy itself that makes the
difference, but the other knowledge that has been
gained in the classes, leading to improved hygiene in
the home (such as better use and maintenance of
latrines).
Two week % of diarrhoea % of population Relative cost of
diarrhoea rate cases that could that could the action
without the action be prevented benefit (1)
20% 20% 23% High
17% 24% 94% Medium
18% 22% 79% Medium
A child of a literate mother is 50% more likely to have
a short duration diarrhoea, when compared with a child
of an illiterate mother. Literate mothers are more likely
to give fluids, more likely to give fluids on day one of
illness, more likely to give Jeevan Jal and more likely
to know how to prepare Jeevan Jal correctly. But these
gains from literacy do not explain the shorter duration
of diarrhoea; there are evidently some other factors
related to literacy other than these specific actions.
Who needs to know what...
Education programmes about diarrhoea should include
clear messages about when it is necessary to seek help
and about giving extra fluids and continued feeding.
Carers need to seek help when there is blood in the
diarrhoea but they probably do not need to seek
medical help for short duration diarrhoea without blood
in the stool, when they should rather give correct ORT
at home. They need to know how important it is to
give fluids from the first day.
The task is not simply to pass out knowledge; many
households already know the importance of giving
extra fluids but far less manage to put this knowledge
into practice when a child has diarrhoea.
Discussions in focus groups indicate that mothers do
not have time to sit with a child and give frequent extra
fluids, because of other commitments. To change
practice mothers will need to find ways to overcome
their time constraints. Messages about the shorter
duration of diarrhoeal illnesses (and hence less need to
seek expensive outside help) when extra fluids are
given promptly can help them to make decisions about
use of resources: a day at home giving the child
frequent fluids may save time and expense later (quite
apart from saving suffering of the child).
Planners in Government and in NGOs need to know
the potential benefits of provision of safe water and of
iv
programmes of latrine provision, hygiene education
and women’s literacy classes.
This Report and the previous reports in the NMIS
series1,2 are only the first step in publicising the NMIS
findings so that they can be widely discussed and acted
on.
v
The important messages for action from the NMIS
need to be communicated to households, and to
planners in Village Development Committees, District
Administrations and central Government. The
communication has to be to all those who need it, not
only to the sentinel communities. For different
segments of the target audience the key findings remain
the same but the detailed content and medium of the
messages will differ. The task is large and complicated
but very important if the work of the NMIS is to
achieve its aim of improving the lives of people in
Nepal.
 CONTENTS

Executive Summary i-v

INTRODUCTION 1
NEPAL TARGETS FOR KEY INDICATORS 2

METHODS 3
Background: NMIS methodology 4
Methods for the third NMIS cycle 4
Sample sites 4
The population included in the survey 4
Instruments 4
Training and practical aspects of the fieldwork 5
Analysis 5
Weighting of results to give national indicators 5

RESULTS 6
I BASIC DESCRIPTIVE INDICATORS 6
Diarrhoea 6
Diarrhoea incidence 6
Duration and severity of diarrhoea 6
Views about causes of diarrhoea 7
Management of diarrhoea: knowledge and practice 8
Source of information about management of diarrhoea 9
Water sources and access to water 10
Water sources 10
Access to water 10
Perceived problems with water supply 11
Community information about water sources 11
Water treatment and perceived quality 11
Sanitation arrangements 12
Latrine coverage 12
Perceptions and handling of excreta 12
Literacy 13
II EFFECTS OF VARIABLES ON THE INCIDENCE AND SEVERITY OF DIARRHOEA 13
Incidence of diarrhoea 13
Type of water source 14
Treatment of drinking water 14
The water container 14
Handwashing practices 14
Latrines 15
Literacy 16
Diarrhoea duration and severity 16
Giving fluids during the diarrhoea 16
Use of Jeevan Jal 16
Literacy of mother 17
Seeking care for children with diarrhoea 18
III RELATION BETWEEN NMIS FINDINGS AND OTHER INFORMATION 18

CONCLUSIONS 20
Basic indicators 20
Action analysis 20
Getting the messages to those who need them 21

REFERENCES 21

vi
 LIST OF TABLES AND FIGURES
Tables
Table 1. Effects of different variables on the rate of diarrhoea in children under 5 years old iv
Table 2. Nepal goals for diarrhoea, water and sanitation 2
Table 3. Duration of diarrhoea and presence of blood in the stool 7
Table 4. Household views about cause of most recent episode of diarrhoea in 8,312 children under 5 years 7
Table 5. Sources of Jeevan Jal among the 144 communities 9
Table 6. Places or people from whom care was sought for 4,098 children with diarrhoea 9
Table 7. Information about diarrhoea management in the 17,227 households 9
Table 8. Problems with water supply described by 17,227 households 11
Table 9. Presence of a latrine and access to 'safe' water 12
Table 10. Household reasons for not having a latrine among 17,227 households 12
Table 11. Water source and risk of diarrhoea 14
Table 12. Type of water source and household treatment of drinking water 14
Table 13. Treatment of drinking water and risk of diarrhoea in children 14
Table 14. Adult use of latrines and risk of diarrhoea in children 15
Table 15. Literacy of mothers and risk of diarrhoea in children 16
Table 16. Association between giving fluids (at any time) and duration of diarrhoea 16
Table 17. Timing of fluids and duration of diarrhoea 16
Table 18. Use of Jeevan Jal in fluid regime and duration of diarrhoea 16
Table 19. Literacy of mother and duration of diarrhoea 17
Table 20. Literacy of mother and giving fluids during children's diarrhoea 17
Table 21. Literacy of the mother and blood in the stool of a child with diarrhoea 17
Table 22. Presence of blood in the diarrhoea and seeking medical help for the child 18
Table 23. Duration of diarrhoea and seeking medical help for the child 18
Table 24. Literacy of mother and seeking medical help for the child 18
Table 25. Piped water access in the NMIS cycle 3 and the Living Standards Survey 19

Figures
Figure 1. Summary of NPA goals and indicators for NMIS cycle 3 i
Figure 2. Diarrhoea within the last two weeks by age 6
Figure 3. Incidence of diarrhoea by Region and in urban and rural sites 6
Figure 4. Duration of most recent episode of diarrhoea in children under 5 years 6
Figure 5. Duration of diarrhoea by Region and in urban and rural sites 7
Figure 6. Household knowledge about amounts of food and fluids
that should be given to a child with diarrhoea 8
Figure 7. Amounts of food and fluid given to children during most recent episode of diarrhoea 8
Figure 8. Sources of water in the wet season 10
Figure 9. Types of water source by Region and in urban and rural sites 10
Figure 10. Timely access to 'safe' water by Region and in urban and rural sites 10
Figure 11. Latrine coverage by Region and in urban and rural sites 12
Figure 12. Perceived relative hazard of different types of excreta 13
Figure 13. Literacy of carers of young children by Region and in urban and rural sites 13
Figure 14. Literacy of mother and household knowledge of Jeevan Jal preparation 17

ANNEXES

Annex 1. Location of sites in the NMIS A1(1)-A1(4)

Annex 2. The instruments used in NMIS cycle 3
Annex 3. The focus group themes A3(1)
Annex 4. Weighting of results to give national level indicators A4(1)-A4(8)
Annex 5. Results by Eco-development region A5(1)-A5(5)

vii
INTRODUCTION
The Nepal Multiple Indicator Surveillance (NMIS)
began in 1994, with a first cycle on Health and a
number of other indicators that were necessary to
assess progress towards goals nationally as well as
forming a basis for national and local planning. A
second cycle on Primary Education took place in the
summer of 1995. Reports on both first and second
cycles are available1,2. The NMIS process comprises
repeated cycles of data collection, analysis,
interpretation and feedback about issues important to
the health and well-being of the population of Nepal.
Childhood diarrhoea is an important cause of morbidity
and mortality and so diarrhoea incidence and severity,
plus the related topics of water supply and sanitation
were identified as issues to be investigated in the NMIS
process. The first cycle of the NMIS produced brief
information about diarrhoea incidence and water and
sanitation coverage. The third cycle, which is the
subject of this report, focuses on these issues in more
detail. Target levels for several indicators related to
water and sanitation and management of diarrhoea have
been set as part of the Nepal National Plan of Action
for Children and Development. This report includes a
review of progress towards these targets as indicated
by the findings of the NMIS.
The format of this third report in the NMIS Series
includes a brief background to the methodology used in
the NMIS, which will be relevant especially for those
readers who have not seen the first two reports in the
NMIS Series1,2. It describes the methods used in the
third cycle, including the instruments used and the
sources of data from households, institutions, key
informants and focus groups. The Results chapter is
divided into three sections: the first section describes
the levels of relevant basic indicators; the second
section gives the findings of the risk analysis to
examine the effects of variables on the risk of
diarrhoea; and the third section considers the results in
relation to other relevant information. Results
disaggregated by Eco-development region are given in
annex 5. The Conclusions chapter considers the
implications of the results for households and planners
at local and national level.
A two week workshop on the methodology used in the
NMIS and the findings of the third cycle was held in
Kathmandu in May 1996. This was aimed at staff of
the Central Bureau of Statistics who are taking on the
task of data collection for the NMIS as from cycle 5
(due to commence in early 1997). It is planned that
these staff, supported by New ERA and UNICEF staff,
will hold a series of regional workshops after the
completion of NMIS cycle 4 to present and discuss the
findings of NMIS cycles 3 and 4 with local government
staff, local NGOs and other relevant people.
Work on planning and implementing a communication
strategy on the results of the NMIS is currently being
undertaken, with the support of UNICEF. This
includes establishing a network of all organisations,
mainly NGOs, working on nutrition and other aspects
of child health and well being. This network can be a
key channel for communicating messages derived from
the NMIS cycles, since many of the organisations have
frequent contact with communities and part of their role
is the promotion of health through teaching people
about such things as good nutrition, immunisation and
prevention and management of diarrhoea.
Future cycles of the NMIS will revisit some of the
issues covered in earlier cycles, allowing an estimate of
the effectiveness of programmes and interventions. For
example, in cycle 4 (fieldwork completed in November
1996) anthropometric measurements have been
repeated to estimate the proportion of children with
acute and chronic malnutrition (as measured in cycle 1
in 1994), as well as seeking detailed information about
child feeding practices. A future cycle will revisit some
of the key areas for action identified in cycle 3 to assess
progress in implementing changes.

This report and the reports of cycles 1 and 2 are only

the first stage of the action needed to communicate the
results of the NMIS to those who need them for
planning and development at national, local,
community and household levels. As with cycles 1 and
2, the findings of cycle 3 have already been discussed
in a series of workshops. For this cycle, a one day
seminar was held for senior government officials in
Kathmandu in May 1996 (the fieldwork for cycle 3
took place in February to April 1996).

1
NEPAL TARGETS FOR KEY INDICATORS

The National Programme of Action for Children and
Development for the 1990s3 includes several indicators
relevant to NMIS cycle 3, quoting figures for 1990 and
targets for 1996, 1998 and 2001. These figures and
targets are also given in the UNICEF Master Plan of
Operations for Nepal4. Information from these
documents is shown in Table 2.
Data on the three target areas are available from the
NMIS third cycle: management of diarrhoea in young
children, access to safe water, and access to sanitary
means of excreta disposal. These 1996 data can be
used to assess progress towards the NPA goals.
Ideally, they should be close to the 1996 target figures.

Table 2. Nepal goals in relation to diarrhoea, water and sanitation

Global goals for 2000 1990 situation in Nepal Intermediate goals Nepal goals for 2001

1996 1998

Knowledge of diarrhoeal disease 65% knowledge 90% 90% 100% knowledge

control and correct use of ORT 2% correct use 25% 50% 65% correct use

Universal access to safe drinking Rural: 35% 50% 65% 35% to 75%
water Urban: 66% 75% 84% 66% to 90%
Total: 37% 53% 67% 37% to 77%

Universal access to sanitary means Rural: 3% 12% 21% 3% to 25%

of excreta disposal Urban: 34% 50% 67% 34% to 75%
Total: 6% 16% 26% 6% to 31%

The 'correct use of ORT' means, since 1993, giving
extra fluids and continuing with feeding. Some people
insist 'continuing with feeding' means giving the same
or more food than usual but a more realistic
interpretation is giving food (even if less than the
normal amount). The progress towards the goal for
this indicator in 1996 can be directly estimated from
this third cycle of the NMIS. The way of assessing
knowledge of diarrhoeal disease control is not specified
in the documents about the goals for the 1990s.
However, there is information about this area in this
NMIS cycle, including household reports of where they
get their knowledge from.
Access to safe drinking water means access either in
the home or within a reasonable distance from the
home. In Nepal, 'safe' drinking water is considered to
be piped water or water from a spring, borehole or
hand pump. Reasonable access is concerned with the
distance to the water source and the flow rate of water
from that source. An approximation to the targeted
distance of the water source from the home and the
flow rate of the source is the ability to collect water
(journey both ways and time to fill container) within ten
minutes. The proportion of households meeting this
approximate criterion can be estimated from this cycle
of the NMIS.
Sanitary means of excreta disposal is taken to mean
access to a latrine, either an individual latrine for a
household or reasonable access to a public latrine. The
proportion of households with latrines can be estimated
from this cycle of the NMIS.
As well as these indicators with goals in the National
Plan of Action (NPA), this cycle gives information
about other indicators that can be followed over time to
assess progress. These include the two week diarrhoea
incidence, the proportion of households knowing how
to prepare Jeevan Jal and the proportion of households
giving Jeevan Jal as part of the fluid regime for
children with diarrhoea. The cycle also provides
information about literacy of the mothers (or other main
carers) of children under 5 years old. This relates to
the adult literacy targets in the Education section of the
NPA which was the subject of the NMIS cycle 22.

2
METHODS
BACKGROUND: THE NMIS METHODOLOGY
The NMIS uses a methodology known as Sentinel
Community Surveillance (SCS). This is described in
detail elsewhere5,6,7. It has the underlying aim of
'building the community voice into planning'. SCS can
be described as a multisectoral community based
information management system. There are a number
of particular features of the SCS methodology.
‘ Data are collected from cluster sites, selected
to be representative of a district, a region or a
country.
‘ Typically, cluster sites are communities of
around 120 households, and all households in
the site are included in data collection.
‘ SCS is a repeated cyclical process, with each
cycle including planning and instrument
design, data collection, data analysis and
interpretation, and communication of results.
‘ Each cycle focuses on a particular area or
problem, rather than trying to collect data on
a wide range of problems.
‘ Quantitative data from household
questionnaires are combined with qualitative
data from focus groups, key informant
interviews and institutional reviews from the
same communities (that is, the data are
coterminous) to allow a better understanding
of the quantitative data. This combined
analysis is called mesoanalysis6.
‘ Data analysis is not only in terms of
indicators (for example, rate of childhood
diarrhoea) but also in terms of risk (for
example the risk of diarrhoea in a child with
access to safe water compared with a child
who does not have access to safe water).
‘ Data analysis, and especially risk analysis, is
intended to produce results in a form that can
be useful for planning at household,
community, district and national levels.
‘ The same sites are revisited in subsequent
cycles of data collection, allowing easy
estimation of changes over time or as a result
of intervention.
‘ Each cycle of data collection and analysis
requires a communication strategy to get the
information to those who need it for planning.
‘ Transfer of skills of data collection, analysis
and communication over a number of cycles
are an explicit aim of the methodology.
3
SCS is deliberately designed to concentrate data
collection efforts: in time (a series of cycles in the
sentinel sites, at approximately 6 monthly intervals); in
space (representative communities are surveyed rather
than collecting data from all communities); and in
subject matter (each cycle focuses on one area at a
time, rather than trying to collect all possible data on
every occasion). SCS employs a type of cluster survey
methodology, but the clusters are larger than in many
cluster surveys: typically 100-120 households per site,
rather than the 10-50 used in most cluster surveys.
And in the SCS method, there is no sampling within
each site; every household is included. This gives
greater statistical power in the data analysis and also
allows the linkage of data from the household
questionnaires to other, mainly qualitative, data from
the same sites. This data relating to the whole site is
combined with the household data in a mesoanalysis6.
A key issue in the SCS methodology and in the NMIS
is the selection of sites so as to be representative. In
many countries, random sampling is not a possibility
because no adequate sampling frame exists. In these
situations, purposive selection is used, drawing on local
knowledge of conditions to choose sites as
representative as possible of the situation in a district,
region or country. When possible, random sampling
methods are used and this is the case in Nepal, where
a reasonably good census sampling frame exists. In
both cases, stratification is first used to ensure that
certain types of site are included in proportion to their
occurrence in the population. For example,
stratification can be by urban and rural sites, or by
ecological zones. In the NMIS, the sample sites for the
cluster surveillance were drawn by the Central Bureau
of Statistics (CBS), after stratification into development
regions, ecological zones and urban/rural sites. The
details of the sampling method and the selected sites
are given in the report of the first NMIS cycle1 and the
annexes to that report.
As explained above, the same sites are visited in
successive cycles of SCS. After a number of cycles, it
is sometimes desirable to draw a partial or complete
new sample to avoid any possible loss of
representativeness due to repeated visits to the same
sample sites. This is mainly a problem if messages and
possible interventions are concentrated in the sample
(sentinel) communities, rather than being disseminated
via a broader communication strategy. The need to
draw a partial or complete new sample in the NMIS
will be reviewed in subsequent cycles; the third cycle
used the same sample as the first and second cycles.
METHODS FOR THE THIRD NMIS CYCLE
Sample sites
As mentioned above, these are the same sites as for the
first and second cycles, selected by a multi-stage
random sampling method. As discussed in the report
of the first NMIS cycle, the sites are representative of
the country, of the five development regions, of the
three ecological zones, of the 15 eco-development
regions, and of urban and rural situations. The rural
sites were selected primarily to give representation of
the 15 eco-development regions but in 18 districts
there are sufficient sites (four or more) to ensure
reasonable district representativeness. In a further 19
districts, only 1-2 sites were selected so they cannot be
relied upon to be representative of that district. Note
that representation of the 15 eco-development regions
is among the rural sites only; the urban sites are
stratified separately and are not intended to be part of
the representation of the different eco-development
regions. This reflects the high proportion of the
population living in rural communities (around 90%)
and the difficulty of having a large enough urban
sample to stratify separately among the 15 eco-
development regions.
There are a total of 144 sites in the sample: 126 rural
and 18 urban. The location of the sites is shown on the
map in Annex 1. Annex 1 also gives the names of the
Districts in the NMIS sample, with the number of sites
in each. It also includes a list of all Districts in Nepal
grouped into the 15 eco-development regions. This
allows officials from non-NMIS Districts who read the
report to find which results most nearly approximate to
their situation (the results for the relevant eco-
development region).
The population included in the survey
A total of 18,604 households were visited in the 144
sites. Information was available for 17,227 households
(93%); the remainder were closed, had no adults
present or refused to give information (20; 0.1%). The
total population in the households interviewed was
99,265 people; there were 13,338 children under 5
years old for whom detailed information about episodes
of diarrhoea and their management was collected.
Information was collected from:
‘ 17,227 households
‘ 99,265 people
‘ 13,338 children under 5 years old
4
In each of the 144 communities, key informants were
interviewed about the water and sanitation
arrangements in the community and the local
availability of Jeevan Jal. Water sources and other
relevant conditions were observed by the visiting team.
A focus group of mothers of children under 5 years was
held to discuss the prevention and management of
diarrhoea, water and sanitation arrangements.
Instruments
The instruments used in cycle 3 are reproduced in
annex 2. They include a household questionnaire, a
focus group guide, a guide for the observation of the
community and a guide for interviews with key
informants. The instruments were designed in
collaboration with members of the NMIS Steering
Committee, taking into account the advice and views of
UNICEF and government staff working in health,
particularly in the field of diarrhoeal illnesses, and the
advice of government and UNICEF staff working on
water and sanitation.
Instruments used in NMIS cycle 3:
‘ Household questionnaire
‘ Key informant interview guide
‘ Observation guide
‘ Focus group guide
The household questionnaire includes questions about
literacy of the mother (or other caretaker) of children
under 5 years, questions about incidence and
management of diarrhoea for each child under 5 years
in the household; and questions about the source of
water and sanitation practices in the household.
The interview with key informants (knowledgeable
people in the community) seeks information about the
construction and maintenance of water sources in the
community and the source of Jeevan Jal. The
observation guide also collects information about water
sources and their maintenance. The more detailed
information from key informants and the observation
guide about water sources will be the subject of a
separate report.
The focus group guides cover questions on beliefs
about causes and management of diarrhoea, views
about drinking water locally, and views about latrine
construction and use. In particular, the questions of the
best way to give local people advice about diarrhoea
prevention and management and latrines were
explored.
Coding sheets and data entry formats were created for
each instrument. The data were entered and
cleaned using the FoxPro database programme and
later converted into EpiInfo (version 6) for analysis.
The questionnaires and other data collection
instruments were piloted several times to ensure that
they were appropriate to the households, key
informants and focus groups concerned and that the
coding and data entry arrangements were satisfactory.
Training and practical aspects of the fieldwork
Field staff were recruited in January 1996. They were
recruited from and trained in three regional centres:
Kathmandu, Birgunj and Nepalgunj. Ten teams, each
containing five or six members, were recruited. Each
field team had two or three female members. The ten
field teams and ten field supervisors were trained in
Kathmandu between January 17 and 28 1996. Four of
these teams and supervisors then went to undertake
field work in the Hills ecozone. Four supervisors went
to conduct training in Birgunj and two went to conduct
training in Nepalgunj. They were accompanied by the
New ERA NMIS Project Coordinator and Project
Associate and two Research Assistants from New
ERA. Training in Birgunj and Nepalgunj took place
between 1 and 9 February 1996. In each of the three
training centres, at least two field pilot tests of the cycle
3 instruments were carried out, for checking the
instruments and for training of the field staff. After the
training phase, four New ERA staff were assigned to
give intensive supervision of the field data collection.
It was planned to conduct fieldwork in two phases: the
first phase in those 34 Districts where there is no
problem of access in the winter; and phase two in the
3 Districts - Kalikot, Jumla and Mustang - that are not
accessible in January and February due to snow cover.
But it was not possible to conduct fieldwork in Rolpa
during the first phase because of civil unrest. Thus the
fieldwork was conducted in three phases: phase one in
33 Districts between 29 January and 25 March; phase
two in the three mountain Districts between 25 March
and 12 April; and phase three in Rolpa between 24
April and 12 May.
When communities were revisited during cycle 3, the
opportunity was taken to give them a summary of the
results of cycle 2 and conduct focus groups to discuss
the implications of the key findings and the ways in
which important messages might best be disseminated.
Data coding and entry began during the fieldwork
programme, with messengers bringing back as much
data as possible to Kathmandu from each of the field
teams. Data entry began on 1 March 1996.
5
Analysis
The analysis had several aims: to produce national
indicators for the health (especially CDD) and water
and sanitation sectors in Nepal; to examine variables
that might explain the levels of childhood diarrhoea;
and, most importantly, to look for contrasts so as to
discover actionable factors that might help to improve
the situation in these sectors in the future. The first of
these aims was met with descriptive analysis of the data
collected from the households, key informants and
observations. The second two required an analysis to
examine the risk of certain situations of interest (such
as the occurrence of diarrhoea in the last two weeks) in
relation to possible explanatory variables (for example,
the literacy of the carer, the source of drinking water
for the household, the presence and use of latrines).
The effects of variables in combination were examined
using multiple stratification techniques.
The analysis was performed using the EpiInfo package
(version 6)8. This public domain computer package
that assists with questionnaire creation, data entry and
data analysis. The strength and statistical significance
of associations was tested using the Mantel-Haenszel
X2 test9 and the Mantel Extension of this test10.
The quantitative analysis was supplemented by
qualitative data from focus groups, key informants and
observation. The records of the 144 focus groups (one
for each community) were reviewed to get an overview
of the ideas expressed. Each focus group was then
coded according to the issues raised by the participants.
These codes were then related to information from the
household questionnaires from the same community.
The focus group themes are shown in annex 3, with the
frequency of each one.
Weighting of results to give national indicators.
As explained in the report of the first cycle of the
NMIS1, the sample sizes of Districts were not
proportional to the populations of the Districts and
weights (or 'raising factors') were calculated to take this
into account when producing national indicators.
These same weights were used in this third cycle of the
NMIS when giving national level indicators. The
weights for each District (actually each group of rural
and urban sites) are shown in annex 4, together with
tables to show the application of these weights in
calculating national values for key indicators. In
practice, the weighted values are almost the same as
the unweighted values for the key indicators. The
values for different Regions and Eco-development
regions in Annex 5 are shown unweighted. Unless
indicated otherwise, values of indicators quoted in the
Results section for the whole of Nepal are weighted.
RESULTS
I BASIC DESCRIPTIVE INDICATORS
The cycle gives information on diarrhoea: incidence
among under 5 year olds; duration and severity of
episodes; and management of episodes. It also gives
information on types and access to water sources,
latrine coverage and use, and literacy of household
heads and main carers (mainly mothers) of young
children. This information is set out at national level
and Regional level in this first section of the results,
and Eco-development regional and District level in
Annex 5. The effects of other variables on the
incidence and severity of diarrhoea are described in the
second section of the results.
The incidence of diarrhoea varies across the country
and between urban and rural sites. Diarrhoea is more
commonly reported in rural sites than in urban sites and
is generally more common in the mountains (although
this is not true in all Regions).
Figure 3 shows the incidence of diarrhoea by Region
and in urban and rural sites. Figure A5.1 shows the
incidence of diarrhoea by Eco-development regions.
Figure 3. Incidence of diarrhoea by Region and in
urban and rural sites

Detailed information about water sources from key

informant interviews and the observation guide is not
reported here; it will be the subject of a separate report.

Diarrhoea

Diarrhoea incidence
The indicator of diarrhoea incidence is the proportion
of children under 5 years old who are reported by
respondents to the household questionnaire to have had
diarrhoea in the last two weeks. Among children under
5 years old, 62% are reported to have had diarrhoea at Duration and severity of diarrhoea
some time. 18% of children are said to have had Figure 4 shows the duration of the most recent episode
diarrhoea within the last two weeks. of diarrhoea in boys and girls. In both sexes, just under
half the episodes of diarrhoea lasted 3 days or less and
The proportion with diarrhoea within the last two nearly 90% lasted 7 days or less. The small proportion
weeks is highest among children aged 7-18 months (about 3%) reported as lasting more than two weeks
and slightly higher in boys (Figure 2). The difference could well represent some other pathology rather than
between boys and girls is nearly all in those aged 13-24 infectious diarrhoea, or recurrent episodes with little
months (Figure 2). The reason for this higher rate in respite in between.
boys of this age is not clear; it may be related to
different behaviour or feeding. Figure 4. Duration of most recent episode of
diarrhoea in children under 5 years
Figure 2. Diarrhoea within the last two weeks by
age

The duration of episodes varied geographically and

between urban and rural sites, as shown in figure 5.
The percentage of episodes lasting more than 3 days

6
was higher in rural sites and in the Mid and Far West
Regions. The duration in different Eco-development
regions is shown in Annex 5, Figure A5.2.
Figure 5. Duration of diarrhoea by Region and in
urban and rural sites
Overall in Nepal, 58% of episodes of diarrhoea
lasted more than 3 days.
The presence of blood in the stool is an indicator of
severity of the diarrhoeal illness. Blood is reported
present in the stool in 19% of the episodes of diarrhoea
in this study. Blood is only half as likely to be found in
the stool when the diarrhoea episode lasts three days or
less (Table 3).
Table 3. Duration of diarrhoea and presence of
blood in the stool
Duration of diarrhoea Presence of blood in stool
Yes No
1-3 days 400 (13%) 2627 (87%)
4 days and above 957 (23%) 3144 (77%)
Odds ratio=0.50 (95% Confidence Interval 0.44-0.57)
Views about causes of diarrhoea
Households were asked about what they thought caused
the most recent episode of diarrhoea in children under
5 years old, in an open-ended question in the household
questionnaire. Their answers have been grouped
together and are shown in Table 4. These answers
from individual households are enriched by the views
expressed in focus groups about the causes of
diarrhoea. A focus group of mothers of children under
5 years was held in each of the 144 communities in the
NMIS sample.
7
Table 4. Household views about cause of most
recent episode of diarrhoea in 8,312 children under
5 years
Perceived cause of diarrhoea number (%)
Stale or dirty food 1019 (12)
Dirty water 171 (2)
Hot or cold weather 3241 (39)
Eating excess food 1135 (14)
Various different foodstuffs 697 (8)
Teething 844 (10)
Lack of time to care for child 50 (1)
Dirty environment 282 (3)
Evil spirits / gods 259 (3)
Infections of various sorts 507 (6)
Don't know 1060 (13)
Similar views about causation of diarrhoea in children
were expressed in the focus groups. Annex 3 shows
the views expressed and the percentage of the focus
groups that mentioned each theme. A higher
proportion of focus groups (18%) attributed diarrhoea
to mothers not having time to care for their children
properly or attend to sanitation:.
"Most men go to India to work. Women have
to do the housework and all the farming work so they
don't give much notice to sanitation or what the family
eats and this causes diarrhoea."
"Males are responsible. They spend their
time gambling, drinking wine, chasing young girls
and gossiping. If they engaged in their homes then the
women would have more time to care for their
children properly. The Government should prohibit
gambling and drinking."
Some people (54% of focus groups) noted the link
between contaminated water and diarrhoea:
"Many children have died from diarrhoea
through lack of fresh water. Diarrhoea is spread
through dirty water."
The problem of lack of education was noted when
attributing diarrhoea to dirty water:
"We are uneducated and don't know to boil
the water or use water purifiers"
Occasionally, mythology about diarrhoea causes
persists (3% of households, rare in focus groups):
"The evil side of the God enters children's
bodies sometimes and causes diarrhoea. The witches
of the village are the cause of diarrhoea."
Management of diarrhoea: knowledge and practice
Households were asked about how much food and
fluids a child with diarrhoea should be given, compared
with normal. They were also asked to describe how to
prepare Jeevan Jal. Another part of the questionnaire
asked about the amount of food given and the amount
and timing of fluids given during the most recent
episode of diarrhoea for each child. A specific
question concerned the use of Jeevan Jal. A few
households, especially in the Terai zone and in urban
sites, reported using other oral rehydration salts (ORS)
such as Shakti Jal and Electrobion. Since this is rare
and it is difficult for the interviewers to make the
distinction, these other ORS preparations have been
counted in with Jeevan Jal in this report.
Figure 6 shows the household knowledge about giving
food and fluids during diarrhoea. Almost half think that
the child should be given more fluids than usual and
only one third think that less fluids than usual should be
given. On the other hand, nearly three quarters think
that the child should be given less food than usual.
Figure 6. Household knowledge about amounts of
food and fluids that should be given to a child with
diarrhoea
Reported practice of giving fluids and food during a
child's most recent episode of diarrhoea is less good
than knowledge. As shown in Figure 7, nearly half of
the carers reported giving no fluids during the most
recent episode of diarrhoea and only a quarter reported
giving more fluids than usual. Most (83%) gave less
food than usual or no food.
The target for giving food and fluids to children with
diarrhoea is framed in terms of the proportion of
children with diarrhoea given extra fluids and
continued feeding (see Table 1). If this indicator is
taken to include giving any food (even if less than
normal amounts) the figure from cycle 3 of the
NMIS is 20%, close to the target for of 25% for
1996.
8
Figure 7. Amounts of food and fluids given to
children during most recent episode of diarrhoea
If the stricter definition requiring the child to be given
the same or more food than normal is used, then only
4% of the children with diarrhoea in Nepal meet this
standard.
The level of the less strict 'correct use of ORT'
indicator varies quite a bit across the country. It is
higher in urban sites (33%) than rural sites (20%) and
generally higher in the mountain zones of each region,
with little overall difference between Regions. The
geographic variation is shown in Annex 5, Figure
A5.3.
Most households do not know how to prepare Jeevan
Jal (or the other ORS preparations) correctly. One in
ten said they did not know how to prepare Jeevan Jal
and a further two thirds gave an incorrect description of
its preparation, with only a quarter giving a correct
description of Jeevan Jal preparation. The most
common errors were in the proportions of water and
powder that should be mixed to make the solution. In
many cases this was because households would try to
make up a lesser quantity of the Jeevan Jal solution
than the full litre, presumably because they do not give
children with diarrhoea large volumes of fluids (see
above).
Households were asked specifically if they gave Jeevan
Jal during a child's most recent episode of diarrhoea.
About a third of households give Jeevan Jal to a
child with diarrhoea; this is about two thirds of those
who give any fluids to a child with diarrhoea. Key
informants in each of the communities reported on the
usual sources of Jeevan Jal (or other ORS
preparations) locally. Table 5 shows the sources they
reported.
 "If a village person tells them about
diarrhoea people won't listen but if an outsider comes
Table 5. Sources of Jeevan Jal among the 144 and advises them then villagers will listen with
communities interest. The advisor has to be an outsider, otherwise
Local source of Jeevan Jal Number (%) people won't cooperate."

Medical shops 109 (76) Others feel that local women should be trained to give
advice (29%):
Health posts 71 (49)
"One or two literate women from our village
Retail shops 27 (19) should be trained about diarrhoea. After finishing
their course, they should gather villagers from time to
Hospital 19 (13)
time and explain about diarrhoea."
VHW / FPA / Mobile Health Team 11 (8)
The radio as a means of communication was also
Headquarters / Ward Cttee Office 7 (5) suggested (31% of focus groups):
Benevolent Institution / Volunteers 7 (5) "Melodious songs about diarrhoea
prevention should be composed and played on the
radio."
For about half (49%) of children under 5 with
diarrhoea, the household reported seeking care for the
But others had reservations about the radio:
child outside the home. This was usually 'medical' care
"Not everyone understands what the radio
of some sort. The places or people from whom care
says and not everyone owns a radio."
was sought for the children are shown in Table 6.
Table 7. Information about diarrhoea management
Table 6. Places or people from whom care was
in the 17,227 households
sought for 4,098 children with diarrhoea
Source of information Number (%) hh

Place or person care sought from number (%) Nowhere 183 (1)

Traditional healer 308 (8) Health facility / health workers 5326 (31)

Health post 762 (19) Village Health Worker 181 (1)

Hospital 801 (20) Traditional healer 71 (0)

Village Health Worker 7 (0) Own experience 4186 (24)

Clinic 1217 (30) Family, relations 1440 (8)

Doctor 1052 (26) Neighbours, friends 4096 (24)

Mobile health team 6 (0) Written material 674 (4)

Benevolence centre 19 (0) Radio 2392 (14)

Some children were taken to more than one place.
Television 277 (1)

Source of information about management of Education / schools 212 (1)

diarrhoea in children
Households were asked where they got their NGO personnel 32 (0)
information about what to do for a child with diarrhoea. Health / TBA training 187 (1)
Their responses are shown in Table 7.
Women's training / groups 31 (0)
In focus groups, participants explained where they
Volunteers, educated people 266 (2)
thought it would be best to get information about
causes and management of diarrhoea (see Annex 3 for Municipality / VDC 5 (0)
list of themes raised in focus groups).

Many people feel that villagers would be more

convinced if advice came from outsiders (District or
government 77%, NGOs or other outsiders 43%):

9
Water sources and access to water
Water sources
Nationally, the most common water source is a
handpump (36%), followed by a tap or piped water
(34%) and a well or kuwa (14%). There is little
reported difference in main water source between wet
and dry seasons. The main water sources are shown in
figure 8.
Quite detailed information about the different water
sources in use in each of the 144 communities,
including their origin, maintenance and condition, was
collected from key informants and by observation by
the visiting teams. This detailed information will be
reported separately.
Figure 8. Sources of water in the wet season
The main water source varies across the country,
especially between ecological zones. The different
water sources by Region and between urban and rural
sites are shown in Figure 9.
Figure 9. Types of water source by Region and in
urban and rural sites
Access to water
'Safe' water sources are considered to be tap or piped
water and handpump, borehole or spring water. River
10
water and water from a well or kuwa is not considered
'safe'. The definition of reasonable access used by the
Department of Water Supply and Sewerage of HMG
Nepal is based on distance of the water source from the
house and the flow rate of water from the source. In
discussion, staff from this department thought that their
definition of reasonable access would approximate to
a round trip of 10-15 minutes (including going,
collecting water and coming back). This definition
based on time also takes into account any waiting time
that may be necessary because of heavy use of a public
water source.
Based on these definitions of 'safe' water and
'reasonable access', this survey indicates that in the wet
season 47% of the households in Nepal have access
to 'safe' water within 10 minutes. In the dry
season, the corresponding figure is 44%. These
figures are not yet at the national goal of 53% for 1996
for access to 'safe' water. There could also be some
argument about whether the definition of 'safe' water is
strict enough. Is all piped, borehole, handpump and
spring water really 'safe'?
Note that for water access, the unweighted figures for
Nepal are rather higher than the weighted figures
(Annex 4, table A4.2) because of the particular
distribution of this indicator between Districts and
urban and rural sites.
The access to water varies between urban and rural
sites and between different parts of the country. The
rates of access to 'safe' water within 10 minutes for
different Regions and urban and rural sites in wet and
dry seasons are shown in Figure 10. In this figure,
weighted values for urban and rural sites are given.
The urban target for 1996 (75%) has been met, but the
rural water access is still below the target of 50%. The
rates of access by Eco-development regions are shown
in Annex 5, Figure A5.4.
Figure 10. Timely access to ‘safe’ water by Region
and in urban and rural sites
Perceived problems with water supply
Households were asked what problems, if any, they
experienced with their supply of water. Despite
improving access to water in the country, most
households still perceive some problems with their
water supply. The problems mentioned by households
in response to an open-ended question in the household
questionnaire are summarised in Table 8, after coding
and grouping their responses. Clearly, both difficulty
of access to a sufficient supply and poor quality are
concerns.
Table 8. Problems with water supply described by
17,227 households
Problems with water supply number (%)
No problem 7053 (41)
Too far away, no local source 4673 (27)
Not sufficient supply 4806 (28)
Bad smell, taste, colour etc 1049 (6)
Dirty / infected source 3210 (19)
Crowds, arguments etc at source 1576 (9)
Poor maintenance / management 302 (2)
Problems with journey / source 856 (5)
Focus groups in each site also discussed perceived
problems with water supply (see Annex 3). Many of
the same problems were mentioned. Common themes
were that the source was too far away (52%) or the
supply was insufficient (64%). Poor people in
particular seem to have difficulty finding a good supply
of water in some areas:
"Influential people have installed the
Government handpump in front of their house and
when they are not using it they take off the handle and
stop the water."
"We have to cover long distances and fight
and quarrel for water because the owner of the
handpump refuses to give water. So we have to drink
well water which is dirty; we give this to the children
and they get sick."
"A whole morning is spent to collect a
container of water."
Sometimes (59% of focus groups) the water quality is
obviously bad:
"The water becomes greasy and yellowish
after putting it in a pot."
"There are frogs, germs and straw in the
water from the well."
11
Some focus groups made suggestions for solving their
water problems (see Annex 3). Most (80%) wanted
action from the government or VDC and more than a
third (37%) mentioned the need for good maintenance:
"Clean drinking water is a right for rich and
poor alike. If people in the community get together to
maintain the wells and cover them, the problem of
water shortage will be solved."
"Wells and handpumps should be properly
managed and repaired by Water Use Committees and
villagers themselves. A tap or well should be built for
every 3-4 households."
Community information about water sources
Detailed information about the various types and
condition of water sources found in the communities
will be reported separately. In nearly half (49%) of the
144 communities the key informant reported the
presence of a Water Users Committee and 59% of
these committees have at least one woman member.
Two thirds (65%) of the communities have
experienced a water shortage in the last year.
Water treatment and perceived quality
The vast majority (94%) of households do not treat
their drinking water in any way, whatever the source of
their water. Perhaps surprisingly, households with a
'safe' water supply are twice as likely to treat their
drinking water in some way as households with a water
supply not defined as 'safe' (5% vs 2.5%). More than a
third of households (41%) report that they usually
cover their water containers and just over half (54%) of
those observed were actually covered at the time of the
household interview. Nearly all households (90%)
report that they throw away old water before refilling a
water container.
It was not possible to analyse the effect of type of water
container used because of the large number of options
and the use of multiple types of containers within
individual households. Similarly, while nearly all
households wash out the old water container before
refilling, they use such a wide variety of materials to do
this that it is not possible to analyse the effect of
different washing materials used.
When asked their opinion about the quality of their
drinking water, three quarters (75%) of households say
that their water is good quality. Households getting
their water from a well, kuwa or river are less likely to
think the water quality is good (49%) than those getting
their water from springs, taps, pipes or boreholes
(81%). The latter group are those water sources
considered to be 'safe'.
Sanitation arrangements
Latrine coverage
Most households do not have a latrine, especially in the
rural areas. The commonest type of latrine (8%) is a
simple pit latrine. The coverage with latrines by
Regions and in urban and rural sites is shown in Figure
11. The coverage in different Eco-development
regions is shown in Annex 5, Figure A5.5.
Figure 11. Latrine coverage by Region and in
urban and rural sites
The coverage rates with latrines nationally (15%)
and in urban (63%) and rural (12%) sites
separately have met the 1996 goals set in the Nepal
National Plan of Action of 16% national coverage,
with 50% urban coverage and 12% rural coverage
(see Figure 1). The difference between urban and
rural sites is more marked than in the target figures but
the effect of the high urban rate on the national figure
is reduced by the weighting process.
Households with a latrine are more likely to have
access to 'safe' water (Table 9). This may be because
most Government and NGO programmes combine
water and sanitation activities.
Table 9. Presence of a latrine and access to 'safe'
water
Household has Access to 'safe' water
latrine
Yes No
No 11346 (80%) 2795 (20%)
Yes 2894 (94%) 192 (6%)
Odds Ratio=0.27 (95% CI 0.23-0.31)
Households without a latrine (the big majority) were
asked why they did not have one, in an open-ended
question. After coding and grouping the answers, they
are summarised in Table 10.
12
Table 10. Household reasons for not having a
latrine among 17,227 households
Reasons for not having a latrine number (%)
Problems with resources, space 4793 (28)
No perceived need for latrine 11392 (66)
Problems with smell, privacy etc 520 (3)
Other temporary problems 152 (1)
The main reason given by households for not having a
latrine is lack of a perceived need for one (66%).
Focus group discussions (see Annex 3) gave a slightly
different impression. Only 22% of groups felt that there
was no need for latrines at all:
"What is a latrine? What are you supposed
to do in a latrine? We don't know anything about
latrines."
"Latrines are needed where there is
congested settlement. But in our community there are
many jungles, rivers and public places and we have
no habit of using latrines."
"Why do we need a latrine? We go to the
nearby fields. If we go there our house and the garden
don't get dirty."
Problems with money and sewerage arrangements for
latrines are commonly mentioned (46% of focus
groups):
"People are not eager to invest their money
in building latrines, rather they use it to buy houses."
"Our menfolk are always saying they will
build latrines but they never do. That is why most of
the people in this village do not have latrines."
There is a perception that latrines, especially the simple
pit type, are smelly and polluting (20% of groups):
"The problem is that no-one would clean a
public latrine and it will smell around the place."
"The simple latrine has many problems and
causes pollution."
Perceptions and handling of excreta
Nearly all households hold the belief that cattle excreta
are less hazardous than human excreta and many
believe that baby excreta are less hazardous than adult
excreta. The beliefs expressed about relative hazard of
different types of excreta are shown in Figure 12. The
reported source of these beliefs was mainly (more than
80%) from ‘own experience’ or from friends or
neighbours.
Figure 12. Perceived relative hazard of different
types of excreta.
Households report using animal excreta in a number of
ways. Cattle and buffalo excreta are reportedly used
more commonly than excreta of other animals,
especially for smearing the walls and floor of the house
(37% of households). Nearly three quarters of
households use cattle or buffalo excreta for manure and
about half use the excreta of other animals for this
purpose.
Most (88%) households have an animal shed within
100 steps of their house and 25% have the animal shed
in or attached to the house. However, only 11% of
households report keeping pigs and most of these (8%)
are kept in a pen all the time.
Literacy
Information was sought in this cycle on the literacy of
household heads and the literacy of the main carer of
each child under 5 years old (usually the mother).
NMIS cycle 2 gives full data about literacy by age of
the whole sample population over five years old2. The
national estimates from NMIS cycle 3 are that 47% of
household heads are literate and 21% of carers (nearly
all mothers) of children aged under 5 years are literate.
Nearly all (90%) of household heads are male. The
difference between their literacy (47%) and that of all
males of 15 years and over in cycle 2 (57%) is
explained by the low number of young household heads
(only 14% less than 30 years and only 1% 20 years old
or less) and the strong inverse relationship between age
and literacy found in NMIS cycle 22. The 21% of
carers (mothers) who are literate in NMIS cycle 3 is
close to the figure of 23% for literacy of women 15
years and over found in NMIS cycle 2. The figure in
cycle 3 may be an underestimate since it is based on the
literacy of the mother of each child under 5 years old
and illiterate mothers are likely to have more children
13
than literate mothers. The figure in cycle 2 is based on
the literacy of each woman in the household.
Figure 13 shows the literacy of carers of children
under 5 years old by Region and in urban and rural
sites.
Figure 13. Literacy of carers of young children by
Region and in urban and rural sites
II EFFECTS OF VARIABLES ON THE
INCIDENCE AND SEVERITY OF DIARRHOEA
IN YOUNG CHILDREN
The effects of variables likely to increase or decrease
the risk of occurrence and severity of diarrhoea have
been examined. This is in order to indicate ways in
which the risk of diarrhoea and the risk of severe
diarrhoea might be reduced by changing the levels of
associated variables. For this reason, the analysis
concerns mainly those things that are relatively
amenable to change: such as literacy, presence of
latrines, type of water source, treatment of drinking
water, fluids given during diarrhoea. Action to change
these things may be required at household, community,
District or National level. Diarrhoea in children under
5 years is used as an index of health effects associated
with contamination of food and water and poor
sanitation.
Incidence of diarrhoea
Several variables might be expected to be associated
with the risk of diarrhoea occurrence in young children
and questions about these were therefore deliberately
included in the questionnaire. The variables examined
are: type of water source; perceived water quality;
treatment of drinking water; covering of water
container; handwashing practices; presence and use of
latrines; proximity to animal sheds; literacy of
household head and literacy of the child's carer (usually
mother).
Type of water source
'Safe' water sources (tap, pipe, handpump, borehole,
spring) were compared with other water sources (river,
well, kuwa). A child in a house with a 'safe' water
supply has only three-quarters of the risk of
diarrhoea of a child in a house with an 'unsafe'
water source (Table 11).
Table 11. Water source and risk of diarrhoea
'Safe' water source Diarrhoea in last 2 weeks
Yes No
Yes 1742 (16%) 8901 (84%)
No 469 (20%) 1837 (80%)
Odds Ratio=0.77 (95% CI 0.68-0.86)
Risk Difference=0.039
It seems that households may be right to have a lower
regard for the quality of their water if it comes from a
river, well or kuwa (see above). But there is no
association between perceived quality of water (from
any source) and the occurrence of diarrhoea. People
apparently judge water quality mainly on the basis of
such things as taste, smell and colour; water which is
heavily contaminated with pathogenic organisms may
appear perfectly good quality.
Access to the water source may also influence the risk
of diarrhoea in children. In communities where the
focus group mentioned a problem with the water
source being far away, or the water from the source
being insufficient for their needs, children had a higher
risk (about 1.2 times the risk) of having diarrhoea in
the last two weeks.
Treatment of drinking water
As mentioned above, very few households do anything
to their water before drinking it, whatever its source.
In fact, households with access to a 'safe' water source
are twice as likely to treat their water in some way as
households with an 'unsafe' water source (Table 12).
Table 12. Type of water source and household
treatment of drinking water
'Safe' water source Treat drinking water
Yes No
Yes 707 (5%) 13297 (95%)
No 74 (2.6%) 2817 (97.4%)
Odds Ratio=2.02 (95% CI 1.57-2.61)
Despite the low number of households treating their
drinking water, there is an association between treating
the water and the occurrence of diarrhoea. A child
14
from a house that treats drinking water has only
three quarters the risk of diarrhoea of a child from
a house that does not treat the water (Table 13).
The effect is probably diluted because some of the
types of water treatment used, such as simple filtration,
are not likely to be very effective.
Table 13. Treatment of drinking water and risk of
diarrhoea in children
Treat drinking water Diarrhoea in last 2 weeks
Yes No
Yes 53 (13%) 345 (87%)
No 2130 (17%) 10227 (83%)
Odds Ratio=0.74 (95% CI 0.54-1.00)
Risk Difference=0.039
There is an interaction between the effects of water
source and treatment of water in the household such
that in houses that treat water the beneficial effect of a
safe water source is greater; and when the water source
is not safe, the rate of diarrhoea is actually higher when
the water is treated than not treated. This again
probably reflects the poor methods of water treatment
used and suggests that they are not effective for heavily
contaminated water.
The water container
An attempt was made to examine the effects of different
types of water container but so many different types
were reported that this proved impossible. Nearly all
households report throwing out old water before
refilling the container and this practice is not associated
with the risk of diarrhoea. The large number of
different materials used to wash out the water container
meant it was not possible to assess the effects of
different materials on the risk of diarrhoea.
Somewhat surprisingly, while there is a small
difference in the rate of childhood diarrhoea between
households that cover the water container and
households that do not cover the container (16% v 18%
rate of diarrhoea), this difference could be due to
chance. There is also no association between whether
the water container was observed to be covered and the
risk of childhood diarrhoea. This suggests that the
important stage of water contamination is before it
reaches the house. There is no interaction or
confounding between covering the water container and
water source or water treatment in the house.
Handwashing practices
It seems likely that handwashing practices, especially
of those who prepare food, are related to the risk of
diarrhoea. However, in practice this is difficult to
investigate. A straight question such as 'do you wash
your hands before preparing food?' is likely to elicit a
positive answer, whatever the actual practice. The
question used here about 'when do you wash your
hands?' in the event produced so many different and
combined answers that it has not proved possible to
demonstrate a protective effect from handwashing at
certain times. Similarly the responses to the question
about ‘what do you teach your children about when to
wash their hands?’ produced too many different and
multiple responses to allow analysis.
Responses to the question about amount spent on soap
in the last month seemed to indicate that children with
diarrhoea in the last two weeks came from households
who spent less on average on soap than the households
of children without diarrhoea in the last two weeks.
However, when per capita expenditure was calculated,
taking household size into account, there was no
difference.
The household questionnaire and focus group
discussions confirm that people use a variety of
materials to wash their hands, some of which (such as
clay and soil) might be expected to increase bacterial
contamination. Perhaps this is another reason why it is
difficult to show a positive benefit from handwashing.
This is the sort of issue that may require detailed
observational study to sort out. For the moment, other
evidence about the good microbiological effects of
proper handwashing is sufficient to include advice
about handwashing in campaigns to reduce the risk of
diarrhoea.
Latrines
There is a marginally higher rate of diarrhoea in
children from households without a latrine (17%) than
in children in households with a latrine (16%) but the
small difference could well be due to chance. In urban
sites, where around half the households have a latrine,
there is no effect at all of presence of a latrine on the
risk of childhood diarrhoea.
A further analysis has been undertaken to compare the
diarrhoea rates in communities with a high coverage of
latrines with those in communities with a low coverage
of latrines, to take into account the use of other people's
latrines and possible contamination of the area from a
neighbour's latrine. Again, no association has been
found between the level of latrine coverage and the
average diarrhoea rate in communities. The effect of
distance from the house of the nearest latrine has also
been examined. About two thirds of households
(including in urban sites) are not within 100 steps of a
latrine, theirs or anyone else’s. The risk of childhood
diarrhoea does not different between houses differing
distances from the nearest latrine.
15
An attempt was made to examine the latrines for
cleanliness but this was not successful because of the
multiple descriptions used, which made an analysis in
terms of 'clean' vs 'dirty' latrine impossible. It could be
that the negative effect of dirty latrines balances out the
positive effect of latrines overall. The goal in the
Nepal National Plan of Action talks of 'universal access
to sanitary means of excreta disposal'. This is taken as
more or less synonymous with universal coverage with
latrines but this is probably too simplistic, without
taking into account the maintenance and appropriate
use of the latrines. The benefits that are reported from
programmes of increasing latrine coverage are likely to
be as much from increased knowledge and generally
improved hygiene practices as from the latrines
themselves.
There is some evidence that household hygiene
practices, including using a latrine if it is present, make
a difference to the risk of childhood diarrhoea. Among
the relatively small number of households with a
latrine, most adults (98%) use the latrine. If they do
not, this is associated with an increased risk of
diarrhoea. A child from a house where the adults
use the latrine has only half the risk of diarrhoea of
a child from a house where they do not use the
latrine (Table 14).
Table 14. Adult use of latrines and risk of
diarrhoea in children
Adults use the latrine Diarrhoea in last 2 weeks
Yes No
Yes 463 (16%) 2357 (84%)
No 18 (26%) 52 (74%)
Odds Ratio=0.57 (95% CI 0.32-1.02)
When a latrine is present, around 80% of children are
reported to use it. More than half of these are said to
use the latrine by the age of four years and 94% by the
age of six years. The use of latrines by the children in
the household is not, however, associated with the risk
of childhood diarrhoea.
Animals
There is no association between the proximity of the
animal shed to the house and the risk of childhood
diarrhoea. Too few houses keep pigs to allow analysis
of the effects of keeping them in a pen or running free.
Literacy
Literacy of the head of the household is not associated
with the risk of diarrhoea in children; the rate of
diarrhoea is virtually the same for households with
literate and illiterate heads.
But literacy of the child's carer (usually the mother)
does make a difference. A child with a literate
mother has only about three quarters the risk of
diarrhoea of a child with an illiterate mother (Table
15).
Giving fluids during the diarrhoea
There is an association between giving fluids to a child
with diarrhoea and duration of diarrhoea. But this
overall association does not show a protective effect of
giving fluids; in fact, children with longer duration
diarrhoea are more likely to have been given fluids
(Table 16).
Table 16. Association between giving fluids (at any
time) and duration of diarrhoea
Child given fluids Duration of diarrhoea

Table 15. Literacy of mothers and risk of diarrhoea 1-3 days 4 days +
in children
Yes 1542 (40%) 2338 (60%)
Mother literate Diarrhoea in last 2 weeks
No 1444 (46%) 1717 (54%)
Yes No
Odds Ratio=0.78 (95% CI 0.71-0.86)
Yes 357 (14%) 2243 (86%)
When the timing of giving fluids is considered, a
No 1854 (18%) 8495 (82%) different picture emerges. It is important to give fluids
Odds Ratio=0.73 (95% CI 0.64-0.83) early in the illness. Among children given fluids at all,
Risk Difference=0.042 a child given fluids on the first day is two and a half
times more likely to have short duration diarrhoea
The way in which the mother's literacy affects the risk than a child not given fluids on the first day (Table
of diarrhoea in the child is not clear. Other studies 17).
have shown an apparent increased risk of diarrhoea in
children of literate mothers, probably due to improved Table 17. Timing of fluids and duration of
recognition of the condition in the child. Here any diarrhoea
reporting bias seems to be outweighed by some Timing of fluids given to Duration of diarrhoea
beneficial effect. It could be that hygiene practices of child
literate mothers are generally better, probably because 1-3 days 4 days +
many adult literacy classes include hygiene studies as
First day 870 (53%) 785 (47%)
part of their curriculum. It seems less likely to be an
indirect effect of a higher income, since there is not an Not first day 611 (30%) 1413 (70%)
association with literacy of the head of the household. Odds Ratio=2.56 (95% CI 2.23-2.95)
The effect of literacy of the mother on the risk of
childhood diarrhoea remains when the safety of the Use of Jeevan Jal
water source, the treatment of water in the home, the Among children given fluids of any sort during
covering of the water container, and the presence of diarrhoea, about two thirds are given Jeevan Jal. This
latrines are taken into account by multiple stratification. seems to have an additional beneficial effect; a child
There is some interaction: the effect of literacy of the given Jeevan Jal as part of the fluid regime is
mother on reducing the risk of childhood diarrhoea is nearly one and a half times more likely to have
more marked in houses that have a latrine; and the short duration diarrhoea (Table 18).
beneficial effect of the presence of a latrine seems to be
confined to households where the mother is literate.
Table 18. Use of Jeevan Jal in fluid regime and
Again, this suggests that it is the better hygiene
duration of diarrhoea
knowledge and practice of literate mothers that reduces
the risk of childhood diarrhoea. Jeevan Jal part of fluid Duration of diarrhoea
regime
1-3 days 4 days +
Diarrhoea duration and severity
Just under half the reported episodes of diarrhoea Yes 1072 (42%) 1487 (58%)
lasted three days or less (see above). What increases or
No 470 (36%) 851 (64%)
decreases the risk of an episode of diarrhoea lasting
more than three days? Odds Ratio=1.31 (95% CI 1.13-1.50)

16
This is not explained by an association with timing of Table 20. Literacy of mother and giving fluids
fluids; those children given Jeevan Jal are no more during childhood diarrhoea
likely to be given fluids on the first day than those not Fluids regime Mother literate OR
given Jeevan Jal. (95% CI)
Yes No
Households from communities where 'lack of time to No. (%) No. (%)
care for children' was mentioned in focus groups of Any fluid
mothers are less likely to give Jeevan Jal to a child with given
diarrhoea (Odds Ratio 0.64, 95% CI 0.54-0.75).
Yes 992 (69) 3213 (50) 2.23
(1.96-2.53)
Literacy of mother No 438 (31) 3161 (50)
There is a clear beneficial effect of literacy of the
mother on the duration of childhood diarrhoea. A child Jeevan Jal
of a literate mother is nearly one and half times included
more likely to have short duration diarrhoea than Yes 703 (71) 1953 (61) 1.57 (1.34-
a child of an illiterate mother (Table 19). 1.84)
No 289 (29) 1260 (39)
Table 19. Literacy of mother and duration of
Fluids on
diarrhoea first day
Mother literate Duration of diarrhoea
Yes 508 (53) 1301 (44) 1.48 (1.27-
1-3 days 4 days + 1.72)
No 446 (47) 1689 (57)
Yes 654 (49%) 680 (51%)

No 2378 (41%) 3435 (59%)

Figure 14. Literacy of mother and household
Odds Ratio=1.39 (95% CI 1.23-1.57)
knowledge of Jeevan Jal preparation
There is also an association between duration of
diarrhoea and literacy of the head of the household, but
this is less strong than the association with literacy of
the mother (or other main carer) of the child.

The effect of literacy of the mother may be because

literate mothers are more likely to give correct care to
their children when they have diarrhoea. Indeed,
analysis confirms that literate mothers are more likely
to give fluids during diarrhoea, more likely to give
Jeevan Jal, and more likely to give fluids on the first
day of illness (Table 20). However, taking each of
these other factors into account does not change the
association between maternal literacy and duration of
childhood diarrhoea. So the effect of maternal literacy Blood in the stool is also less likely to occur when the
seems to depend also on other practices. mother of the child is literate. A child with a literate
mother has less than three quarters the risk of
Literate mothers are more likely than illiterate mothers bloody diarrhoea of a child with an illiterate
to give more fluid than usual to a child with diarrhoea mother (Table 21).
(37% vs 21%). They are also more likely to know how
to prepare Jeevan Jal correctly (Figure 14). These Table 21. Literacy of the mother and blood in the
factors may contribute to the better outcome for the stool of a child with diarrhoea
child when the mother is literate. Mother literate Blood in the diarrhoea

Yes No

Yes 212 (15%) 1230 (85%)

No 1247 (19%) 5214 (81%)

Odds Ratio=0.72 (95% CI 0.61-0.85)

17
Seeking care for children with diarrhoea and the mother is literate, more than three quarters of
Mothers are nearly one and a half times more likely to children are referred for medical help.
seek medical care for a child with diarrhoea if there is
blood in the diarrhoea (Table 22).

Table 22. Presence of blood in the diarrhoea and III RELATION BETWEEN NMIS FINDINGS
seeking medical help for the child AND OTHER INFORMATION
Blood in the diarrhoea Medical help sought
Diarrhoea frequency and management
Yes No A study by WHO and the Ministry of Health of HMG
Nepal11 in June 1990 (just pre-monsoon) collected
Yes 852 (59%) 602 (41%)
household information about diarrhoea from sites in the
No 3238 (51%) 3164 (49%) Terai and Midhills. The study reported a two week
Odds Ratio=1.38 (95% CI 1.23-1.56) incidence of diarrhoea in children under 5 of 17% in
the Terai and 19% in the Midhills, similar to the
Similarly, when diarrhoea persists for more than three incidence found in this cycle of the NMIS. A national
days, a mother is one and a half times more likely to survey12 in 1991 (not during the monsoon) found a two
seek medical help for the child (Table 23). week diarrhoea incidence among children under five
years old of 16%, also similar to the cycle 3 NMIS
Table 23. Duration of diarrhoea and seeking result. This suggests little change in the incidence of
medical help for the child diarrhoea among children under 5 years old between
1990 and 1996.
Duration of diarrhoea Medical help sought

Yes No Cycle 1 of the NMIS1 also collected some information

1-3 days 1443 (48%) 1570 (52%)
4 days plus 2444 (60%) 1650 (40%)
Odds Ratio=0.62 (95% CI 0.56-0.68)
The two factors influencing seeking medical care
interact, so that when blood is present in the stool there
is a higher rate of referral whatever the duration of the
diarrhoea. Despite these associations, 46% of children
without blood in the diarrhoea and with diarrhoea
lasting less than four days are referred for medical care,
probably unnecessarily.
On the other hand, less than two thirds of children with
blood in the diarrhoea are referred for medical help.
A child of a literate mother is more than one and a half
times more likely to be referred for medical care of
diarrhoea. (Table 24).
about diarrhoea in children under 5 years old. Field
data collection for cycle 1 took place between January
and April 1995. The incidence of diarrhoea in the last
two weeks in children under 5 years old was 15% in
that study, very similar to the 17% incidence in this
cycle. The data in this cycle was collected from the
same sites and at about the same time of year.
A recent Demographic and Health Survey (DHS)13 in
Nepal collected information from a representative
sample of households throughout Nepal. They found a
two week diarrhoea incidence among children under 3
years of 28%. This is considerably higher than the
figure from cycle 3 of the NMIS and from the previous
Nepal survey12 using the same methodology as this
recent DHS. This recent DHS was conducted during
the monsoon season and it is likely that this explains
the higher rate of diarrhoea since it is widely believed
that the incidence of diarrhoea is higher during the
monsoon period.

Table 24. Literacy of mother and seeking medical If the incidence of diarrhoea has not changed, has its
help for the child management improved? In the 1990 WHO survey11 the
Mother literate Medical help sought authors report that 14% of households in the Terai and
Midhills gave children with diarrhoea Oral Rehydration
Yes No Salts (ORS), lower than the proportion of children
Yes 903 (63%) 540 (37%) given Jeevan Jal in this survey (about one third overall
or two thirds of those given any fluids). They also
No 3195 (50%) 3238 (50%) report that 27% of children with diarrhoea in the Terai
Odds Ratio=1.69 (95% CI 1.50-1.91) were given increased fluids, but only 9% were given
increased fluids in the Midhills. This survey found that
The effect of mother's literacy is stronger if there is 25% of children with diarrhoea are given increased
blood in the diarrhoea; if there is blood in the diarrhoea fluids and 20% are given both increased fluids and

18
continued feeding. On the other hand, the 1991 Table 25. Piped water access in the NMIS cycle 3
household survey12 found that 27% of children under and the Living Standards Survey
five with diarrhoea were given Jeevan Jal and 23% Region % of households with access to piped
were given homemade ORS. The common errors in water
making up ORS observed in the 1990 survey11 are
similar to the errors made when households were asked NMIS cycle 3 LS Survey
to describe how to prepare Jeevan Jal in this survey: Eastern 29 20
people often mix the wrong quantities of powder and
water, especially adding too little water. Central 42 37

Since 1993, the emphasis has shifted and the definition
of correct Oral Rehydration Therapy (ORT) has
become giving extra fluids and continued feeding. This
is the form of the goal in the National Plan of Action3
and is estimated directly in the NMIS cycle 3.
However, it was not directly estimated in either the
recent DHS13 or the first cycle of the NMIS 1
, so
comparison between their findings and cycle 3 of the
NMIS for this indicator is not possible.
Water supply and latrine coverage
The data from the NMIS cycle 3 on water supplies and
latrine coverage can be compared with data from the
Nepal Living Standards Survey Report 199614. This
survey covered 3,373 households throughout Nepal
and fieldwork took place between June 1995 and June
1996. The data on water supply are not quite in the
same form but table 25 shows a comparison between
the NMIS cycle 3 and the Living Standards Survey for
piped water (piped into the house and outside the
house).
Western 60 47
Mid Western 44 22
Far Western 56 30
The higher figures from the NMIS are probably
because they include water from taps other than from
piped supplies, and these sources are not included in
the LS survey figures for piped water. On the other
hand, the LS survey has higher values for all Regions
for water from wells (covered and open); some of this
is being counted as another source in the NMIS cycle
3. There is no specific category for supply from a
pump or borehole in the LS survey.
Latrine coverage is estimated from the LS Survey14 as
being 22% nationally: 67% in urban sites and 18% in
rural sites. The figures for latrine coverage in NMIS
cycle 3 are similar: 15% nationally, 63% in urban sites
and 12% in rural sites.

19
CONCLUSIONS
Basic indicators and NPA goals
Nepal’s National Plan of Action (NPA) for Children
and Development for the 1990's3 sets goals related to
childhood diarrhoea mortality, knowledge and use of
oral rehydration therapy (ORT), water supply and
latrine coverage. The indicators from this cycle of the
NMIS can be compared with the goals in the NPA. The
goals are shown in Table 2 (p.2). The comparison is
summarised in Figure 1 (p.i).
The correct use of ORT (20%), defined as giving extra
fluids and continued feeding, is approaching the 1996
goal of 25% in the Nepal National Plan of Action.
Access to 'safe' water (44%) is below the 1996 NPA
goal of 53% nationally, mainly because of low access
in rural areas. The indicator used here is an
approximation to that used by the HMG Government
Department of Water Supply and Sewerage. The
definition of 'safe' water is quite a generous one; not
everyone would agree that piped water, for example, is
safe to drink in all parts of the country. There is still be
a long way to go to reach the final goal of universal
access to safe water.
'Access to sanitary means of excreta disposal' for which
goals are set in the NPA, is taken as coverage with
latrines. The national latrine coverage (15%) meets the
NPA goal of 16% for 1996. The urban coverage
(63%) more than meets the NPA goal of 50% and the
rural coverage is the same as the 12% goal. The
weighting process means the high urban coverage does
not contribute very much to the national figure. Latrine
coverage may not be synonymous with sanitary means
of excreta disposal if latrines are poorly built and badly
maintained. In this survey, the presence of a latrine
does not reduce the risk of childhood diarrhoea.
Perhaps there is some truth in the perception by
households and communities that latrines are often
unsanitary; many prefer to go into the surrounding area
to defaecate.
Action analysis
Diarrhoea prevention
Continued efforts are needed to provide all
communities with safe water. The universal provision
of water presently defined as ‘safe’ (pipe, tap,
handpump, borehole, spring) could be expected to
reduce the two week incidence of diarrhoea in children
from 20% to 16% (Risk Difference 4%). This
relatively modest potential effect raises questions about
the quality of water from these ‘safe’ sources. Most of
the population (67%) already get their water from these
‘safe’ sources, although only 44% have access to them
within 10 minutes.
20
Water treatment in the home, including crude
methods such as simple filtration, can reduce the risk of
diarrhoea in individual children by one and a half times.
If all households treated water, even by crude means,
the rate of diarrhoea in children could be reduced by
4%. Analysis of interaction suggests this would be
more effective if combined with provision of ‘safe’
water. Most households cannot afford to boil the
water and other methods used are less effective.
Cheap, effective methods of home water treatment are
needed.
Programmes of latrine provision need to emphasize
education and community participation. At present
many households perceive latrines as irrelevant or even
harmful, contaminating the environment and
concentrating infection risk. There is no detectable
benefit of latrines in reducing diarrhoea risk in this
study, except in households where the mother is
literate. The benefit comes in using the latrine, when
the risk of diarrhoea is reduced by about half compared
with those houses that have a latrine but do not use it.
Literacy of mothers is a protective factor. Provision
of adult literacy classes for all women of young
children could reduce the incidence of childhood
diarrhoea from 18% to 14%. It is almost certainly not
the literacy itself that makes the difference, but the
other knowledge that has been gained in the classes,
leading to improved hygiene in the home (such as
better use and maintenance of latrines). All
opportunities should be taken for hygiene training of
girls and adult women, in schools, literacy classes,
women's groups and elsewhere.
Management of diarrhoea episodes
Reducing the severity of episodes of diarrhoea can be
expected to reduce the associated mortality and long-
term morbidity. Key areas for intervention are
maternal literacy, practices of giving fluids and food
during episodes of diarrhoea, and practices of seeking
medical help for children with diarrhoea. The timing
of fluids is all important. A child given fluids on the
first day of illness has less than one half the risk of long
duration diarrhoea compared with a child not given
fluids on the first day.
A child of a literate mother is 50% more likely to have
a short duration diarrhoea, when compared with a child
of an illiterate mother. Literate mothers are more likely
to give fluids promptly but this does not explain the
shorter duration of diarrhoea; there are evidently some
other factors related to literacy other than these specific
actions.
Getting the messages to those who need them
Education programmes about diarrhoea should include
clear messages about when it is necessary need to seek
help and about giving extra fluids and continued
feeding. Carers need to seek help when there is blood
in the diarrhoea but they probably do not need to seek
medical help for short duration diarrhoea without blood
in the stool, when they should rather give correct ORT
at home. They need to know how important it is to
give fluids from the first day.
The task is not simply to pass out knowledge. Many
households already know the importance of giving
extra fluids but far less manage to put this knowledge
into practice when a child has diarrhoea. Discussions
in focus groups indicate that mothers feel they do not
have time to sit with a child and give frequent extra
fluids, because of other commitments. To change
practice mothers will need to find ways to overcome
their time constraints. Messages about the shorter
duration of diarrhoeal illnesses (and hence less need to
seek expensive outside help) when extra fluids are
given promptly can help them to make decisions about
use of resources: a day at home giving the child
frequent fluids may save time and expense later (quite
apart from saving suffering of the child).
This Report and the previous reports in the NMIS
series1,2 and this report are only the first step in
publicising the NMIS findings so that they can be
widely discussed and acted on. The important messages
for action from the NMIS need to be communicated to
households, and to planners in Village Development
Committees, District Administrations and central
Government. The communication has to be to all those
who need it, not only to the sentinel communities who
form the sample for the NMIS. For different segments
of the target audience the key findings remain the same
but the detailed content and medium of the messages
will differ. The task is large and complicated but very
important if the work of the NMIS is to achieve its aim
of improving the lives of people in Nepal.
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21
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