Managing Hygiene Promotion in WASH Programmes

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13 – Managing hygiene promotion in WASH programmes Developing knowledge and capacity GGUIDEUIDE 1133 About WEDC in water and sanitation The Water, Engineering and What makes us stand out from the Development Centre is one of the crowd is our outreach to practitioners. world’s leading education and research We use our knowledge base and our institutes for developing knowledge applied research work to develop Managing hygiene promotion in and capacity in water and sanitation the capacity of individuals and for sustainable development and organizations throughout the world, WASH programmes emergency relief. promoting the integration of social, technical, economic, institutional and We are committed to the provision Managers of water, sanitation and hygiene (WASH) programmes normally environmental activities as foundations of effective, evidence-based and acknowledge that people need to behave in a hygienic manner to protect water for sustainable development. appropriate solutions for the supplies and ensure that sanitation facilities are used properly. However, improvement of basic infrastructure Visit our website to find out more about promoting hygienic behaviour differs from the construction of infrastructure, and essential services for people living our postgraduate and professional with indicators of progress being less concrete. This means campaigns need to be in low- and middle-income countries. development programmes (MSc, planned and carried out in a suitable manner. With over 45 years of experience, we Diplomas and postgraduate certificates offer expert advice and quality learning available at the University or by Contents opportunities for sector professionals. distance learning); our research; our Background ...... 1 advisory services; our international What is hygiene? ...... 1 Founded in 1971, WEDC is based in the conferences; and our extensive range Principles of hygiene promotion...... 3 School of Civil and Building Engineering of information resources which are at Loughborough University, one of the Planning a hygiene promotion programme ...... 8 free to download from our knowledge top UK universities. Being a part of a Participatory tools ...... 12 base. leading university gives us a recognised Analysis of the data ...... 15 platform of independence and quality. http://wedc.lboro.ac.uk Implementation of the action plan ...... 16 Methods of hygiene and sanitation promotion ...... 20 Selecting and training facilitators ...... 21 Monitoring and evaluation ...... 21

A number of studies have suggested that the impact of hygiene practices on sanitation- related disease could be as great as that of the actual provision of sanitation facilities. Effective hygiene promotion is widely believed to be one of the most valuable tools we have to change people’s behaviour, which in turn can protect them from diarrhoeal diseases. It can also be a helpful way to encourage participation and empower Water, Engineering and Development Centre communities. Despite the acceptance of its importance, hygiene promotion is often given School of Civil and Building Engineering far less emphasis than traditional water supply and sanitation activities in development Loughborough University settings. This guide is designed to help address this issue. Leicestershire LE11 3TU UK

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Authors: Brian Reed and Jane Bevan

Edited by Louise Medland

Illustrations by Rod Shaw

Quality Assurance: Hazel Jones

This guide is one of a series of published learning resources which are available for purchase in print or to download free of charge from the WEDC Knowledge Base. Any part of this publication, including the illustrations (except items taken from other publications where WEDC does not hold copyright) may be copied, reproduced, translated or adapted to meet local needs, without permission from the author/s or publisher, provided the parts reproduced are distributed free, or at cost and not for commercial ends and the source is fully acknowledged.

Please send copies of any materials in which text or illustrations have been used to WEDC at the address given below.

Published by WEDC, Loughborough University Funded by Water & Sanitation for the Urban Poor (WSUP)

ISBN 978 1 84380 168 9

“ To be successful in our hygiene education programmes, we have to spotlight human behaviour.

At the beginning of a programme we need Water, Engineering and Development Centre to investigate what behaviours are posing School of Civil and Building Engineering health risks and so should be addressed by Loughborough University hygiene education activities. Leicestershire LE11 3TU UK At the end, we need to assess what T: + 44 (0) 1509 222885 Linkedin: WEDC UK changes in behaviour have occurred that E: [email protected] Twitter: wedcuk are beneficial to health.” W: wedc.lboro.ac.uk YouTube: wedclboro (Source: Boot and Cairncross, 1993) 24 1

from earlier monitoring exercises should HARVEY P, BAGHRI S, and REED R 2002 Background be available to inform the evaluation. Emergency Sanitation: Assessment and The adoption of hygienic practices is often much harder in low-income settlements Such an evaluation may be useful to Programme Design. WEDC, Loughborough than in affluent areas with good infrastructure. Not only do poor homes lack the basic assess long-term strategies within an University, UK facilities taken for granted by richer people, but the problems may be compounded organisation, and to compare with other HARVEY, P. A. 2007 Excreta Disposal in (especially in peri-urban areas) by poor drainage, unsurfaced streets and inadequate similar projects elsewhere. Emergencies: A field manual. WEDC, solid waste management in the settlement as a whole. These all contribute to an Loughborough University, UK. unhygienic environment. References SPHERE PROJECT, 2004 Sphere • hand washing with soap after contact ALMEDOM, A.M., BLUMENTHAL, U. and Handbook: Humanitarian Charter and What is hygiene? with faecal matter and before food MANDERSON, L. 1997. Hygiene Evaluation Minimum Standards in Disaster Response, The word hygiene itself is derived from preparation; and Procedures: Approaches and Methods for OXFAM Publishing. Oxford UK the Greek hygieinos meaning healthful, or Assessing Water- and Sanitation-Related relating to health. As we generally use it, • improving water quality at the Hygiene Practices. International Nutrition the term hygiene is the ‘practice of keeping household level. Foundation for Developing Countries oneself and one’s surroundings clean, (Almedom et al, 1997) especially in order to prevent illness or the BOOT, M. and CAIRNCROSS, S. 1993. spread of disease’ (Boot and Cairncross, The F-diagram Actions Speak: The study of hygiene 1993). Diarrhoea is primarily transmitted behaviour in water and sanitation projects. through faecal-oral routes (i.e. from The Hague, The Netherlands: IRC Hygiene promotion is the term used to faces to mouth). The diagram commonly International Water and Sanitation Centre describe activities that aim to encourage used to depict these faecal-oral and London UK: The London School of changes of behaviour with the ultimate goal transmission routes is known as The Hygiene and Tropical Medicine. of preventing water- and sanitation- related ‘f’ diagram, pictured overleaf. It shows CURTIS V and SMITH L 2005. diseases. It has been defined as ‘the how faecal material can be transmitted Hygiene Promotion, WELL factsheet. planned and systematic attempt to enable through fingers, flies, fields, fluids, floods Loughborough, UK: Loughborough people to take action to prevent water and and food to get into a person’s mouth. University. sanitation related illness, and to maximise FERRON, S., MORGAN, J. and O’REILLY, the benefits of water and sanitation M. 2007. Hygiene Promotion: A practical facilities’ (Ferron et al., 2007, p.12). manual for relief and development, 2nd Edition. UK: ITDG Publishing. Hygiene practices to prevent diarrhoea GOOD, A. 1996. ’Social Issues in NGO A person can reduce the risk of getting Water Projects’ in Ian Smout (ed.) 1996. diarrhoea by at least 35% if they follow any Water and NGOs. Proceedings of an ODA of these hygiene practices: Workshop. WEDC, Loughborough UK: Loughborough University. • using a pit latrine to dispose of faeces – Figure 1. Cleanliness is essential for including children’s faeces health 2 23

The ‘f’ diagram At least some of the methods used for Types of evaluation The movement of pathogens from the faeces of baseline assessment should be used Barriers can stop the transmission of Evaluation attempts to establish how a sick person to where they are ingested by W WATER disease; these can be primary somebody else can take many pathways, some again during monitoring and evaluation, (preventing the initial contact with the successful the hygiene promotion direct and some indirect. This diagram illustrates S SANITATION faeces) or secondary (preventing it being the main pathways. They are easily memorized so that useful comparisons can be made programme has been in achieving the ingested by a new person). They can be as they all begin with the letter ‘f’: Å\PKZ(drinking controlled by water, sanitation and water) MVVK, ÅPLZ, ÄLSKZ(crops and soil), ÅVVYZ H HYGIENE between the findings, to show what stated objectives. A good evaluation finds hygiene interventions. and (and surface water generally). ÄUNLYZ ÅVVKZ changes take place over time. out how far each project objective has been achieved and why some objectives For sustained monitoring activities, Treat, transport and store have not been fully achieved. It is usually the water safely community monitoring is a very effective W carried out once the project has been tool, as the element of peer pressure can running for a fixed amount of time, Protect the be very powerful. Diagrammatic charts water source W fluidsluids allowing enough time for behaviour can be adapted for selected families or changes to occur. The first evaluation Separate S Wash hands faeces from before eating groups of families to monitor their own would typically be after one year. water sources Wash hands or preparing after defecation food hygienic practices, episodes of diarrhoea An internal evaluation can help to guide in children, and so on. H H Store and cook the future direction of the programme, food carefully This can be compared later with while an external evaluation typically fingers monitoring data from other sources, and assesses to what extent the programme H is a powerful tool to generate support for has achieved its overall objectives. For Cover food the programme within a community. either type of evaluation, information faeces food faces H S There is now a strong body of evidence that demonstrates hygiene promotion to S Wash hands be effective in producing lasting and sustainable behaviour change. Cairncross Separate faeces before eating from the flies Control and Shordt (2004) conducted a review of hygiene programmes in six countries or preparing environment ñLHV Wash food H H hands to assess their sustainability. Positive hygiene behaviours were found to have S Peel and wash improved the long-term health status of many participants. Their key findings food were as follows:

• Sustained hygiene promotion interventions are needed for lasting behavioural change - access to services alone is not enough, fields • Better take-up of positive behavioural change is strongly correlated with the greater educational level of women, and

Drainage • The most intensive programme interventions – using small groups and S personal contact – are most effective in creating lasting good hygiene behaviour. floods Primary barrier Secondary barrier

Note: The diagram is a summary of pathways: other associated routes may be important. Drinking water may be contaminated by a dirty water container, for example, or food may be infected by dirty cooking utensils. 22 3

activity, carried out by project staff and Sustainability – will the targeted prevent initial contact with the faeces. members of the community. Results of behaviour changes continue once the Figure 2. The ‘f’ diagram (left) Secondary barriers such as hand any monitoring must be fed-back into the project is over? washing and proper storage of food The movement of pathogens and water prevent faecal material from decision-making processes that inform Unintended outcomes – unpredicted (disease-causing organisms) from being ingested by a new person. It is the future direction of the programme. ‘side-effects’ of the programme – these the faeces of a sick person to where particularly important to focus on the If possible, monitoring information can be positive or negative. should come from more than one source, they are ingested by somebody else safe removal and disposal of the faeces to support or corroborate findings, in In addition, it is useful to consider can take many pathways, some of babies and young children, as they the process known as triangulation (at replicability, both in terms of the direct and some indirect. contain a higher proportion of disease- causing organisms than adult faeces least three sources) or cross-checking community’s ability to continue with This diagram illustrates the (Ferron et al, 2007). (Almedon et al., 1997). and expand the campaign developed, main pathways. They are easily and in terms of the transferability of the Six key indicators can be used; memorized as they all begin with strategy or campaign to another setting. the letter ‘f’: fluids (drinking water) Principles of hygiene promotion Appropriateness – have the right Hygienic behaviours help to keep both Regular monitoring of the activities food, flies, fields (crops and soil), activities been used at the right time? people and their environment clean. The held should be considered part of floors, fingers and floods (and aim of hygiene promotion is to encourage Effectiveness – has the activity had the the record-keeping duties of the field surface water generally). intended impact? people to modify their actions, so they workers (Ferron et al., 2007). For health The diagram is a summary of reduce high-risk unhygienic behaviours Efficiency – has the activity been data, a link with the relevant clinics or pathways: other associated routes and adopt appropriate behaviours and conducted in the most time-efficient and hospitals should enable access to weekly may be important. Drinking water use of appropriately designed facilities cost-efficient way? or monthly data on the incidence of may be contaminated by a dirty (including hand washing units, latrines diseases. Participation – do all sector groups of the water container, for example, or food and water storage vessels). Such change target population attend meetings? Are may be infected by dirty cooking all attendees participating? utensils. Types of monitoring The type of monitoring required depends on the overall design of the approach and Improved hygiene practices play a major the intended outcomes. role in breaking these transmission Participatory monitoring techniques routes. As people improve their hygiene involving members of the community in behaviours, such as hand washing after assessing changes in hygiene practices coming into contact with faecal material can be very effective. Participatory and drinking water from a protected monitoring not only increases community source, the risk of disease transmission ownership but also enables them to is significantly reduced. identify solutions for encouraging behaviour changes and ensures Barriers to faecal-oral Figure 16. Checking if people wash their transmission hands with soap can be difficult sustainability of improved hygiene Figure 3. A cover for food is only effective behaviour. Primary barriers such as the use of a when in use latrine and protected water sources 4 21

needs to be voluntary and typically only health or to the local environment if it is leaders. Literacy and numeracy are sanitary facilities among adults and occurs when people want to change. affected by the risk). helpful but not always vital skills: if children; someone is a good communicator, they Participation of users in hygiene • basic health messages and their may be able to rely on their colleagues to promotion can encourage greater Hygiene promotion is a resource- limitations; record their progress. awareness of the reasons for changes intensive process, needing significant • use of songs, drama, puppet shows, in hygiene behaviours, together with time, skilled educators and suitable Many rural water and sanitation projects etc.; ownership and sustained take-up of materials to ensure that relevant train voluntary village health workers hygienic practices. messages are received and acted on who can provide on-going motivation for • gender issues; by people. It is not possible – or cost- The actual risk associated with any hygienic practices beyond that delivered • targeting various groups and particular unhygenic practice is a effective – for a hygiene promotion during visits from project workers. especially vulnerable groups within combination of the likelihood of that risk programme to try to address the full Typically, these are women resident in the the affected area; occurring (i.e. how widespread a practice range of practices that might result villages concerned, who are respected • monitoring and evaluation activities. it is) and the severity of the outcome in a health risk to people, or to the members of the community. (i.e. how dangerous it is to a person’s environment. While this approach is widely used, it must be recognized that there is a limit to Monitoring and evaluation the amount of time that busy, poor people A closer look at hygiene promotion Monitoring and evaluation are essential can devote to voluntary activities. components of any project cycle. • It is the planned and systematic attempt to enable people to take action to Given the significant resources that prevent water and sanitation related illness, and to maximize the benefits of Training are invested in all stages of a hygiene improved water and sanitation facilities. The training of facilitators also needs promotion programme, it is important to to be considered in some depth. This • It combines insider/affected population knowledge (what do people know, do allocate sufficient time and resources to is particularly important if you are and want) with outsider knowledge (e.g. the causes of diarrhoeal diseases, carry out regular monitoring throughout asking health workers who are used to communications and learning strategies). the programme for an effective a traditional didactic style of teaching to • It includes (but is not exclusively) the provision of information and learning evaluation at certain stages. undertake a more participatory form of opportunities regarding aspects of personal and environmental hygiene, communication. Monitoring and evaluation help to identify including water provision, excreta disposal, drainage, solid waste disposal and the effect of an intervention, in terms of vector control (more commonly known as hygiene education). The training of facilitators should focus achievement of activities, outcomes and on the following topics; • It makes better hygiene possible in an emergency by providing essential items resulting changes. that may be in short supply, such as water and food storage containers, soap • communication skills; and menstrual protection. Monitoring helps you keep track of • health problems related to sanitation activities, to ensure that the programme • It provides the crucial link between people in the community and the technical in emergency situations and is heading in the right direction. It will interventions during all stages of a project cycle. suggested prevention strategies; also allow you to assess the effectiveness • Hygiene promotion has a narrower focus than health promotion, but both of the promotional methods used, to • traditional beliefs and practices; attempt to enable people to take action to prevent illness. see if and where improvements can be • promotional methods for the use of made. Monitoring is usually an internal 20 5

preferences and the characteristics of sustainable and beneficial to health. The following principles for good hygiene Hygiene messages need to be positive where the PHAST approach is to be used. The hygiene education component of promotion have been identified (WELL, People learn best when they laugh! They SSHE therefore promotes the adoption of 2005), based on experience from various listen for longer if they feel entertained. Social marketing of sanitation healthy practices (such as washing hands projects. Hygiene programmes and messages Social marketing makes use of marketing that attempt to threaten or frighten the with soap after using a latrine, or keeping Target a small number of risky tools and techniques that promote audience, or that tell them they are ‘dirty’ latrines clean), that help prevent water practices hygienic practices by appealing to and sanitation-related diseases. or ‘uneducated’, will alienate them. Priorities for hygiene behaviour change people’s individual interests – such as should normally include hand washing the convenience, status, or wider social Whatever the approach, it is common to Identify appropriate channels of benefits gained from improved sanitation select and train facilitators who carry with soap (or a local substitute) after communication (such as handwashing with soap, or out the hygiene promotion activities in a contact with faeces and the safe disposal It is important to understand how the owning a family latrine and keeping it specific area. of adults’ and children’s faeces. Targeting target audiences communicate. For clean). too many practices at the same time example, some people will listen to the dilutes the message and often reduces radio, others attend social or religious Social marketing is used to promote the Selecting and training facilitators the overall impact. functions, and others go to school. adoption of behaviours that can lead to Making use of traditional and existing Target specific audiences improved health and well-being, not only Selection channels of communication is easier then These may include mothers, children, for the individual concerned but also for Depending on the cultural norms of the setting up new ones, but they will only be older siblings, fathers, opinion leaders, or the wider community. society, potential facilitators may be effective if their nature and capacity to other groups. There is a need to identify male or female and could include elders, reach people are understood by the user. School Sanitation and Hygiene who is involved in childcare and who traditional birth attendants, or community Education influences children or takes decisions for SSHE is an approach to hygiene them. In addition, there is a need to find promotion based on the premise that out if particular groups are in the habit of children have a right to basic facilities doing things that put them, or others, at in the school setting: including risk of contracting a disease. accessible toilets, safe drinking water, clean surroundings and information on Identify motives for behaviour hygiene. Children who have access to change these facilities can attend school, learn Motives for changing behaviour are more effectively and share the concepts often unrelated to health. People may of good sanitation and hygiene with be persuaded to wash their hands to other family members. Children who receive respect from their neighbours, so are suffering from poor health, such as that their hands smell nice, or for other worm infections, have a reduced ability to reasons. Working with the target groups learn. This in turn affects their future life can help to identify a range of views of prospects. SSHE considers not only the the benefits of safer hygiene practices, Figure 4. Motives for hygiene behaviour facilities required to improve the school Figure 15. Using dance for which can then provide the basis for a need to be understood environment, but the supporting hygienic communication hygiene promotion strategy. practices that make these facilities 6 19

Written text will not be appropriate if people are illiterate, but carefully chosen images may be used to communicate key messages. In many situations, well- written dramas and/or songs can be effective. Decide on a cost-effective mix of communication channels There are many ‘tools’ that can be used for communication. Several communication channels giving the same messages can reinforce each other. There is always a trade-off between reach, effectiveness and cost. The mass media (such as television, radio and newspapers) Figure 5. Radio broadcasts can be has the potential to reach many people, expensive but reach many people but their messages are soon forgotten. Face-to-face communication can be population coverage achieved (e.g. what highly effective in encouraging behaviour proportion of target audiences heard a change, but is very expensive per capita. radio broadcast?) at regular intervals during the promotion programme. Allocate enough resources In marketing, it is said that a person Indicators of the impact of messages typically needs to hear a ‘message’ on the target behaviours must also be six times over, in different formats collected and fed-back into the planning (on a poster, through a home visit, in process, so that money is not wasted conversation, etc.), to ‘receive’ that on hygiene promotion activities that are message. That is, a number of exposures largely ineffective. to the message are needed if that Table 1 outlines suggested minimum message is to be understood and retained. objectives for a hygiene promotion Hygiene promotion requires programme in an emergency context. careful planning, execution, The Sphere Handbook (particularly monitoring and evaluation relevant for emergency situations but Information is required about the range of also applicable in a development context) outputs (e.g. how many radio broadcasts, has a strong emphasis on community Figure 14. Example of hygiene promotion poster (Source: UNICEF, no date) or house visits, are to be made?), and the mobilization. 18 7

Educational materials, such as a series form of a short drama or interview. Table 1. Recommended minimum objectives for hygiene promotion of pictures or flipcharts, can be used to (Adapted from Harvey et al, 2002) Some basic market research can help guide the discussion. Home visits are to determine the best times of day to sensitive, so visitors must be sufficiently broadcast, to reach the widest audience. Criteria Immediate Short-term Long-term trained before carrying them out. Television and radio broadcasts are more Posters likely to be effective in urban areas, due Quality Facilitators from the same 50% 75% 100% social background as those Posters and other printed material to the limited number of people who can they work within can portray simple messages to a afford to own a television or radio in many large audience. They can be prepared rural areas. Facilitators trained 50% 75% 100% relatively cheaply, in consultation with the community, but they are less likely to Promotional messages are 50% 75% 100% change behaviours on their own. Methods of hygiene and accurate, appropriate to target audience and cover The main message should be displayed sanitation promotion the topic completely pictorially, supported with a limited In addition to the tools already discussed number of words. Images should be there are several well-known methods Messages are delivered in a 50% 75% 100% realistic and true to scale, clearly showing which can be adopted to promote way that is compatible with socio-cultural aspects the chosen action. Materials should be sanitation in communities. pre-tested locally to ensure the pictures PHAST: Participatory Hygiene and Quantity Number of facilitators per 122+ and text convey the correct message. 1000 people Sanitation Transformation Posters should be displayed in public PHAST is an approach to promoting Coverage of area of 50% 75% 100% places, where they can be noticed by hygiene and sanitation improvements, by implementation the maximum number of people. These using a series of methods and materials include markets, schools, medical to stimulate community participation in Percentage of sanitation 50% 75% 100% centres, places of worship, water the development process. topics covered collection points and public latrines. Impact Population receiving, 30% 50% 75% Sometimes large murals can be painted PHAST makes extensive use of trained understanding and on walls of buildings. extension workers and sets of graphic materials (called ’tool kits’). Tool kits remembering messages Radio and television are modified and adapted to suit local Percentage of population 30% 50% 75% Radio and television broadcasts may well putting messages into be the most effective method of reaching practice a large number of people. The broadcast should be entertaining, clear and brief – Percentage of messages 30% 50% 75% ensuring that it catches people’s attention actually implemented by the population and leaves a memorable message, Figure 13. Leaflets can contain detailed perhaps by using a slogan or jingle. A mix written information These percentages are just indicative of progress rather than absolute values. of voices is preferable, perhaps in the The ideal (100% level) is subjective and will depend on local conditions. 8 17

The key indicators related to the standard Planning a hygiene promotion • One to one home visits; Flip charts, handbooks or comparative for hygiene promotion are as follows: programme • Mass campaigns/announcement; pictures can be used to facilitate • Radio/TV/Video; and group discussions. Choice of the most The planning stage involves setting • Key hygiene risks of public health • Posters / wall charts / leaflets / logos appropriate material will depend on the the aims and objectives that you importance are identified. on t-shirts, etc. size and nature of the group, but the hope to achieve from the hygiene same material can often be used with promotion programme. The objectives Community drama • Programmes include an effective either adult or children’s groups. can be divided into three levels, which Drama is an effective way to mechanism for representative collectively lead to the aims of the project communicate a message to an entire Home visits and participatory input from all (Ferron et al., 2007). community, including children. Members These are the most time-consuming users, including the initial design of of the community should be involved as options for hygiene promotion, but can facilities. • The aim or goal is a general much as possible, both in planning and in also be very rewarding and generate statement of intent of the entire presenting dramas – they have the deep a great deal of valuable information. A • All groups within the population have programme. insight into hygiene practices in their skilled health visitor or educator can equitable access to the resources • Purpose objectives refer to the wider community. target her/his advice and guidance very or facilities needed to continue or objective of the programme. directly towards each family and their achieve the hygiene practices that are Puppet shows, stories, songs, circumstances. It is also possible to promoted. • Outputs are the results that the dances discuss individual concerns and more project should be able to guarantee If a high proportion of the target group personal questions, including ones • Hygiene promotion messages and will happen, necessary for achieving are children, such as school children, that would not be mentioned in public activities address key behaviours and the purpose and the aim. highly interactive forms of entertainment meetings. misconceptions and are targeted to will help to engage them and keep their all user groups. Representatives from • Activities refer to the practical attention. Puppet shows, using plenty of these groups participate in planning, actions (e.g. promotional events music and a simple talk to convey a clear training, implementation, monitoring and materials) that will be taken to message, can be very effective. Puppets and evaluation. achieve the outputs, purpose and are adaptable (for example, you can have aim/goal. a talking fly!) and children may find it • Users take responsibility for the easier to talk to a puppet than to an adult. management and maintenance Group discussions and talks of facilities as appropriate, and Group discussions create an opportunity different groups contribute equitably. for debate between community members In particular, the guidance warns about why people carry out a particular against the tendency to over-burden hygiene practice and how it can be one section of the population with this improved. Certain hygiene practices, task. such as excreta disposal, are better discussed in a gender-based focus group. Figure 6. Planning a hygiene promotion For some topics, groups may need to be Figure 12. Individual or small group (Source: Sphere Project, 2004) programme based on certain age ranges. meetings allow in depth discussions 16 9

• identify who (groups of people rather are to be effective. Methods used to than individuals) carries out the most promote hygiene practices should not common (perhaps up to three) and be authoritarian, relying on one-way easily changeable practices; communication. Rather, they should be people-centred, involving at least two- • discuss and agree on existing way communication and ideally multi- communication methods within the community that could be way communication. This is what enables used for hygiene promotion, the sharing of knowledge, ideas and or the appropriateness of new experience. communication methods (e.g. mobile Hygiene messages are more effective video projection); if given in the local language(s). Any • identify indicators for monitoring pictures and drawings that you plan to changes in hygiene practices; and use should always be pre-tested with a small group in the community, before • agree on who, and how often, the they are adopted for general use. indicators should be monitored. It is recommended that a participatory Implementation of the approach be adopted throughout action plan the implementation of the action Having decided on which key hygiene plan. Involving representatives of the messages will be focused on initially, you community is vital to gain their trust Figure 7. Risky behaviours need to be identified need to start implementing the hygiene and cooperation in any health promotion promotion programme. During this stage, campaign. Participation is also important hygiene messages will be disseminated, for the community to develop an A plan for a hygiene promotion programme should include: using the chosen methods and tools. understanding of their own vulnerability, Existing community groups can help to and the hazards they face, in order to be • An overall aim or goal; more aware of the health risks, and to do this, if they are thought to be suitable. • One or two purposes (e.g. targeted hygiene practices); Alternatively, the community may decide begin to develop sustainable solutions. to form a specific group who will be • Two to four outputs; Tools for hygiene promotion responsible for these activities. A variety of communication methods can • A series of activities for achieving each of the outputs; Project staff may start the hygiene be used: • Measurable indicators and means of verification for each level of the promotion activities, gradually training • Community drama; objectives; the community groups to join in so • Puppet shows and games, storytelling that they can eventually take over full • Identified target audiences for the hygiene promotion; and and songs responsibility for the activities. • Large and small group discussion • Action plans for achieving the objectives (e.g. weekly activities and allocation Messages developed to communicate (perhaps using pictures, charts or of responsibilities). what makes for good hygiene practices cards); need to be clearly understood if they • Talks; 10 15

What type of information is should give you the information you need. • What communication channels exist Health may not be a community required? Using more than one method to cross- and how can they be used? priority The key baseline information required check information and ensure its validity Involving the community in the collection should identify the risks associated with is known as triangulation. An evaluation of WaterAid’s South and/or analysis of baseline information practices around water supply, excreta India programme found that Triangulation is important because will be more effective in achieving disposal, environmental sanitation and local people almost invariably people may tell you something that is ownership of that information. Results food hygiene. It is advisable to only gave health improvements untrue, because they are embarrassed to of the baseline assessment can be collect information that will be used lower priority than providing tell you the truth – in case you then think presented as pictures or symbols that later on. Ferron et al. (2007) suggest water for cattle, irrigation and badly about them. For example, if people can be easily understood by community ten key questions to be answered when kitchen gardens; furthermore, tell you that they always use the latrine, members. Such results can be presented conducting a baseline assessment: within the health sphere they check to see if it looks as if the latrine is in focus groups, giving participants the valued improvements in curative 1. What are the widespread ‘risky’ practices being used regularly (e.g. is there a worn opportunity to discuss the findings. medical facilities more highly than in the community? path to the latrine?) health education and preventive Once high-risk practices emerging from 2. Who and how many employ the ‘risky’ It can be embarrassing, both for the strategies (Good, 1996). practices in the community? the baseline assessment have been questioner to ask, and for the interviewee presented, the focus group can: 3. Which ‘risky’ practices can be altered? to answer some questions. It may also be 4. Who uses ‘safe’ practices? embarrassing for a householder to know • rank the practices according to As is the case with all programmes, clear 5. Who and what motivates and influences that their practices are being observed. In the ones that they think are most them to use ‘safe’ practices? objectives enable you to monitor progress addition, people may not speak the truth common; 6. What communication channels are of the hygiene promotion programme and if other people, or people of the opposite available and which are trusted for • select the key risk practices that they support the final evaluation. There should promoting hygiene? (This can help sex, are present. Tact and careful design think are most easyyg; to change; always be clear indicators against which to ensure that messages are heard, of tools (e.g. using secret ‘pocket chart’ to monitor the objectives, together with received and put into practice by the voting) is often needed to find the truth. community.) specified means of verification. 7. What facilities or materials do Analysis of the data Baseline assessment people need in order to carry out It is important to analyse the information ‘safe’ practices? (For example, if the gathered during the baseline A baseline assessment is the first promotional messages are to promote assessment, so that you can determine: step towards a hygiene promotion handwashing with soap, the programme programme. It provides a means of should seek ways to make soap • Which high risk practices are accessible – otherwise people may be left assessing the existing hygiene practices feeling frustrated, or even angry.) common in the community?; of the target community, helping us to 8. How much time, money or effort are • What are the perceived advantages of understand why people do what they people willing to contribute for those alternative safe practices?; do and identify the range of ‘unsafe’ facilities/materials? practices that will later be targeted for 9. Where will those facilities/materials be • Who within the community carries out available? improvement. Identifying these practices the risk practices?; 10. How will people know that the facilities/ Figure 11. Data needs to be analysed supports the effective planning and materials exist and where they can be • Who influences the people that carry once collected implementation of hygiene promotion. obtained? out the risk practices?; and 14 11

Three pile sorting FOREST V.I.P. RIVER Table 2. Examples of areas to be investigated in a baseline survey A range of drawings relating to defecation FORESTFOREST

V.I.P. habits, water sources, food hygiene, etc. V.I.P. Typical subject Type of baseline information are discussed by participants in small RIVERRIVER area groups. The cards are put on a separate pile according to whether the group Basic information • Population/ Population distribution / characteristics • Community organizations thinks that they depict good, bad or in- • Mortality and morbidity data between practices. All groups then come together to discuss their choices and any Water • Water sources (number, type, location and condition) implications. • Quantity of water used per person per day Pocket chart voting • Water quality Requires a chart with pockets in it, a • Average distance to water sources used for different activities range of pictures depicting sets of related • Distance between nearest latrines and water sources variables (e.g. different types of water Figure 10. Pocket chart voting sources and uses of water) and a set of Hygiene practices • Water collection methods • Methods used for transporting water cards, beads or stones that people can secret, placing a ‘vote’ in the pocket • Water storage practices use to vote. The group first discusses under the picture that corresponds to the • Water use and reuse the pictures, adding more information way they want to vote, for example, under • Hand washing practices if required. Each person then votes in the picture(s) of the water source(s) that • Water source preferences for different activities they use for drinking water, or which they • Evidence of open defecation would prefer. Pictures can be modified • Perceived cause(s) of diarrhoea/ Methods used for treating diarrhoea to suit a wide range of information being looked into (e.g. people’s feelings about a Excreta disposal • Location of defecation sites range of latrine options). • Method of disposal of children’s faeces Focus group discussions • Total number of latrines People with related backgrounds or • Number of latrines in use experiences (e.g. mothers, young married • Latrine structure and cleanliness • Number of users per latrine men, mid-wives, etc.) meet together • Use of anal cleansing materials to discuss a specific topic of interest. • Practice of hand washing after defecating Focusing the groups encourages more open discussion – e.g. women may feel Environmental • Refuse disposal practices able to talk openly without men present, sanitation • Vector control problems (e.g. rodents, houseflies, mosquitoes) or young men may express their view • Management of domestic animals more openly without older men present. • Drainage and presence of stagnant water close to houses Figure 9. Examples of 2 images that can be used for 3 pile sorting It is not necessary to use all of these tools, but a combination of 2-3 of them Food hygiene • Methods of food handling and preparation • Food storage and food reuse practices • Practices for washing and drying of utensils 12 13

• What type of information will I collect? Key informant interviewing Summary of stages in a hygiene • Who is the information meant for? Interviews with anyone who can offer The importance of incorporating promotion plan and the questions • What will the findings be used for? specific information, based on their baseline information on hygiene to be addressed • What resources do I have? knowledge or expertise (e.g. a local behaviour in Eritrea health worker or village leader). In Eritrea, the Ministry of Health Planning: Where do we want to get The baseline information is usually used Interview may cover specific topics (e.g. did some research on health to? to plan hygiene promotion activities and options for water collection), or more behaviours in the IDP camps (Deda, Baseline: Where are we now? provision of water and sanitation facilities general issues relating to health, income Mai Haber and Adi Keshi camps) that will involve the community. The or family structures. in September 2000. The results Action plan: How do we get there? choice of targeted practices and methods showed that the residents knew a Community mapping Monitoring: How far are we from of promotion should therefore make best great deal about health problems Participants are asked to develop a map our destination and are we going in use of ‘insider’ knowledge, to encourage in their camps and knew about the to represent their community / area. It the right direction? greater interest, ownership and take- causes of health problems but that should identify places of significance up of these initiatives at the baseline “there exists a great gap between Evaluation: How do we know that (e.g. schools, markets) and features of survey stage. Involving the community in what people know and what they we’ve got there and how can we do interest to the study (water sources, analysing their particular situation is a do.” Research identified problems better next time? sanitation facilities, etc.). This helps good starting point in this approach. with using latrines, “in spite of the to identify public facilities available efforts Oxfam has made to provide to the community, as well as those at latrines in the camps.” The potties How to collect baseline Participatory tools household-level (latrines, rubbish pits, distributed by Oxfam were not being information etc.). The map can be drawn on the used and children’s defecation was ground with stones and sticks, etc., observed everywhere. To be effective, the assessment needs Exploratory walks to represent certain features. After to use suitable methods. A range of Study team, with or without community Following on from this research completion it needs to be recorded with a methods/tools can be used to collect members, spends time walking an Information, Education and sketch or photographs. the baseline information, depending through the study area, becoming Communication (IEC) strategy was on whether you require quantitative or familiar with the context and observing drafted for the IDP camps. It was qualitative information. behaviours. It may be used to identify presented in a tabulated form with specific information, such as location the problem behaviour matched Quantitative information such as how of water points or evidence of faecal to factors promoting problem much soap a household buys each contamination. behaviour and factors supporting month/year, or how far away their behaviour change. This information water source is, can be collected using Structured and unstructured could then be used to help guide standard research methods, such as a observations the Oxfam programme, particularly questionnaire. Observations may be structured (using concerning health behaviour. a list of pre-selected things to observe), Qualitative information can be collected (Source: Oxfam Eritrea Programme or unstructured. Used to find out using participatory techniques. Assessment, Dec.– Jan. 2000. Cited information on water and sanitation- in Harvey, 2007) Before deciding on the tools or methods related facilities, hygiene practices at Figure 8. Community mapping to be used, consider: these locations and in the home.