arrow_backEmergency WASH

A.2 Risks and Influences affecting Health and Hygiene

Multiple factors affect people’s health and wellbeing, not only access to WASH. In many emergencies, people will have been displaced from their homes and may no longer have a livelihood or access to adequate food, shelter or healthcare. Promoting health is a complex and multifaceted task; it requires all sectors to work together and coordinate their assessment efforts. Interventions need to be prioritised to achieve the greatest possible impact for the largest number of people. Some interventions, such as providing a rapid means of disposing of faeces or supporting community organisations and networks, should be implemented in parallel with the assessment process when the risk to health is high. 

The risks and influences affecting health span across different sectors and interventions. There is a particularly important association between malnutrition and the incidence and severity of diarrhoea. Food hygiene is also vital for improving public health. WASH interventions are also important when responding to outbreaks of certain infectious diseases such as Ebola, COVID-19 or malaria. Even where infectious diseases are not widespread, poor environmental health conditions can have a detrimental impact on physical and mental health and wellbeing and it may still be important to assess and target water and sanitation issues. An important objective of the WASH assessment and response is also to ensure that people can live in dignity and safety. The design of a WASH intervention should contribute to achieving this goal.

Influences on Health (adapted from UNICEF 2013) 

The main pathways for pathogens to infect humans are faeces, fluids, fingers, flies and food and the assessment should identify the specific pathways for the context. The main objective of WASH programmes in humanitarian response is usually to reduce the risk and/or incidence of diarrhoeal diseases by creating barriers along those pathways. 

F-Diagram (adapted from Wagner and Lanoix 1958) 


The ‘F diagram’ (figure above) is a useful model for understanding the transmission routes for faecal oral diseases T.53 and showing ways in which the transmission may be interrupted. It is important to assess and understand these transmission routes to identify which practices are causing a risk to public health. It is also important to assess and understand how different groups in the community understand transmission and the behavioural factors that influence risk and the perception of risk (chapter  B ). 

The process of motivating changes in hygiene behaviour is complex; social, cultural, spiritual, political and legal factors may come into play. The factors that influence hygiene behaviour and practices (chapter  B ) therefore need to be assessed. Behaviour-influencing factors are usually grouped as ‘behavioural influences or determinants’. They can either facilitate change or be a barrier to change. Drivers of, or barriers to change include strong beliefs or feelings (sometimes unconscious) that can positively or negatively influence change. For example, the Community-Led Total Sanitation (CLTS, F.2) approach uses disgust T.45 as a negative ‘driver’ of change and pride as a positive ‘driver’. Different behavioural models B.2 group these drivers and determinants in different ways. The different behavioural determinants need to be assessed to identify which are most important. These determinants often vary in different groups of people and may change over time, creating a need for ongoing assessment.

WASH assessments include multiple factors. Access to appropriate WASH facilities and people’s specific hygiene needs varies between different groups within the community. The response also needs to support people’s dignity, privacy and sense of well-being, as well as interventions to reduce mortality and morbidity and influence behaviour. Women may need support to manage their menstruation effectively and hygienically P.7. Incontinence may be an issue for some groups, such as older men and women and effective means to manage babies’ and children’s faeces will be important for those with young children. Some people may be bedbound, use a wheelchair or have a visual impairment: their hygiene needs will vary. Safety, access and privacy of WASH facilities are important if they are to be widely accepted and used by all sections of the community and these issues will also need to be assessed.

Process & Good Practice

  • Collaborate with all other sectors when assessing, analysing and responding to public health risks P.9. Be aware of the findings from other sectoral assessments to inform priority interventions.

  • Highlight the priority communal, personal and domestic hygiene practices during the assessment. They are often handwashing with water and soap (or when not available ash), after contact with faeces and before eating, safe disposal of adults’ and children’s faeces and drinking clean water. In some contexts it may be important to focus more on specific issues such as food hygiene or waste management.

  • Assess hygiene behaviour and public health risks in various settings such as schools, clinics, feeding centres, community kitchens, child safe spaces and other public places (E.6 and E.8), not just in households and communities.

  • Understand people’s previous hygiene situation and how they have adapted to the current situation.

  • Identify the various behavioural determinants that can influence hygiene behaviour during the assessment to understand how best to influence them. This can be difficult in a rapid onset emergency but it should be possible to conduct formative (in-depth) assessments within the first few months. In-depth studies can be useful at different stages of the response especially if the current HP approaches do not appear to be effective. 

  • Develop and pre-test a communication strategy, methods and tools – an understanding of behavioural determinants will not automatically generate effective communications (chapter  C ). 

  • Manage the quantity of data collected. Numerous factors influence behaviour and the data can quickly become too unwieldy to analyse. The assessment design A.3 should build on what is already known about the different population groups and the context and seek to understand where interventions can have the greatest impact.

  • Vary programme design according to the specific context, using the context-specific data collected during the assessment. For example, to meet the objective of ensuring clean drinking water, one context may require the use of buckets with covers and taps, another may need repairs to household water tanks. 

  • Coordinate with other relevant sectors P.9. The health sector may also carry out (overlapping) health promotion and risk communication activities (including assessments) in the community, making collaboration vital. WASH interventions contribute to wider effects. For example, as well as preventing diarrheal disease, hygiene communication (chapter  C ) ensures that people know how to manage disease at home and when they should seek medical help. 



To assess and deepen an understanding of the factors that affect public health and hygiene practices.


  • Public health is affected by many factors apart from water, sanitation and hygiene. It is important to understand how food and nutrition, access to healthcare, shelter, protection and the environment interact with WASH. 

  • Coordination and collaboration with others P.9 is crucial for an effective assessment of the factors that influence health and hygiene. 

  • The use of timely epidemiological data is essential to ensure that the hygiene promotion (HP) intervention is designed and planned according to current public health risks.

  • A variety of Behaviour Change B.2 and WASH models can facilitate a deeper understanding of the different factors affecting hygiene behaviour.

  • In many acute emergencies, the initial WASH assessment focus is on the use of safe water, excreta management and handwashing, as they are likely to have the biggest impact on disease transmission. However, an ongoing assessment of different risks in each specific context is necessary and risks will evolve over time.


Overview of different emergency sectors and interventions

Sphere Association (2018): The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response 4th Edition

Description of public health risks in emergencies and how to respond effectively

Johns Hopkins University, IFRC (2008): The Johns Hopkins and Red Cross Red Crescent Public Health Guide in Emergencies 2nd Edition

Overview of hygiene promotion assessment and link to public health

UNHCR (2017): UNHCR Hygiene Promotion Guidelines

Information on key behavioural determinants of health and hygiene

Petit, V. (2019): The Behavioural Drivers Model. A Conceptual Framework for Social and Behaviour Change Programming

Information on the links between WASH and nutrition

UNICEF (2016): Nutrition - WASH Toolkit