Promoting Good Hygiene Practices

Published by WaterAid, the IRC International Water and Sanitation Centre, and International Water Centre (IWC), this compilation is designed to strengthen the capacity of organisations to design and deliver effective hygiene promotion programmes leading to the improved health of communities. The compilation of 3 keynote papers and 31 case studies in this publication cover community-based approaches, campaign approaches, focus on school and children, and research and monitoring. They can be accessed here. To assist readers, a 12-page snapshot provides a brief description of each case study. The final section of the snapshot document highlights some of the key learnings from the case studies - presented using an adaptation of the FOAM model (Coombes and Devine, 2009). The FOAM model describes 4 core elements of hygiene promotion programmes that, according to the model, all need to be addressed in order to achieve behaviour change. An 'S' has been added to the model here, in order to draw attention to the importance of sustaining behaviour change. A summary of these lessons learned includes:

• F: Focus practices and focus groups:
  • Know your focus groups - e.g., understand the environment in which practices occur (programmes should begin with research or should assist communities to do self-assessments of their situation; use this information to design programmes and monitor behaviour change); select one or a few focus groups (based on assessment such as: who can influence and support behaviour change?); and consider gender (e.g., ask: are women heard in planning and committees?)
  • Prioritise practices and avoid message overload - e.g., focus on a single or a few behaviours (such as handwashing with soap) at a time, using a campaign or social-marketing approach - not necessarily at a national level (it can be delivered to a smaller intended population such as at the district level). As several of the case studies reveal, most of the community-based programmes approach behaviour change not by focusing on messages, but, rather, on active understanding of high-risk behaviours and good practices through high-quality participatory activities and communication that motivate and empower. Behaviour change programmes can be adapted to the local context by focusing on target behaviours that will resonate strongly with the local audience. Many projects combine some elements of mass media and campaigns together with interpersonal community-based approaches to promote improved practices. For example, the Vietnam Handwashing Initiative is an example of an evidence-based communication campaign for handwashing with soap which also has interpersonal communication activities with mothers and participatory school programs with children. Several case studies focused on the management of menstrual hygiene; these cases combine intensive education with the development of small scale enterprises for the production and sale of menstrual products.
• O: Opportunities existing in the external environment to practice the behaviour:
  • Ensure that there is opportunity to change behaviour at the household and community level: People must have the opportunity to try out new behaviours and this requires certain enabling factors such as sufficient water, toilets, acceptable and affordable products, and social support in the environment.
  • Ensure that there is opportunity to change behaviour at the institutional level - e.g., by setting up a specific hygiene promotion strategy, a dedicated budget for hygiene, a monitoring and evaluation (M&E) component for behaviour change, and adequate skilled staff whose difficult work is valued and reinforced through repeated training, supervision, and discussions on problems that arise in their work). Also, it is suggested that volunteers, who often are at the centre of hygiene promotion activities, are well trained and supported (for example, through encouraging a career structure for volunteers to gradually enter paid positions). It is suggested that "there is huge potential to raise awareness about hygiene through partnerships with private companies at the national and local level....Specific events such as Global Handwashing Day can represent an opportunity for partnership."
• A: Enabling adults and children to acquire the Ability to practice good hygiene behaviour - Some examples are: community role models can ignite interest among households to build their own handwashing station; participatory methods help community people to understand good and risky local hygiene practices and to plan, implement, and monitor local action plans; and focus on small, easy, sequential steps, "do-able" actions. The report also suggests being careful with regard to funding the development of new behaviour change communication (BCC) materials: Find out what exists before re-inventing the wheel, and set up good training and practice so that promoters and teachers can use these materials effectively.
• M: Motivating new behaviours (moving from knowledge to practice), drawing upon the specific drivers of change, not just health.
  • It is important to take time to understand the local "drivers of change" before designing hygiene promotion programmes - e.g., powerful drivers for behavioural change are: the feeling of disgust, the need to protect children (nurture), the need to fit in (affiliation), comfort, and the need to attract others (attraction). Improved health or fear of disease is not the only or strongest driver for practising good hygiene behaviours.
  • Health motivation comes from participatory assessments of good and risky local conditions and practices, through a process of learning from peers, not from top-down education.
  • Mobilise key leaders and their institutions to support an improved practice and to communicate it through their local groups.
  • Many programmes set up new water, sanitation, and hygiene (WASH) or health committees whose activities include hygiene promotion. There is a possible conflict between committees setting their own plans while, at the same time, being told to carry out work decided by others.
  • Many case studies have a school component and give examples of child-centred, participatory learning approaches, including activities that are fun for children to promote hygiene behaviours and children's leadership.
• S: Sustaining and studying behaviour change to determine if the behaviour has been sustained to the point of it being habitual - Suggestions include: address shortcomings in M&E; using only a few indicators, assess existing conditions and practices at the start, then during, at the end of a hygiene promotion programme, and then some time afterwards; use several tools to collect information (e.g., through observations, spot checks, discussions, and group ranking or voting) and then compare the results; "Do not do health impact studies in a project. They are complicated, expensive and must be very carefully done to show valid results"; improve hygiene promotion programme monitoring; and seek better information on the cost of hygiene promotion programmes.

Click here for a 12-page snapshot in PDF format, which provides an overview of the case studies.
Click here to access full versions of the 3 keynote papers and the 31 case studies.