Hygiene Promotion (HP) is a planned, systematic approach to enable people to act and adapt their behaviour to prevent or reduce the impact of WASH-related diseases. It is about making water and sanitation services work or work more effectively, and must be supported by all involved in the response, including government, local or international agencies, NGOs and the affected communities. To address WASH-related disease risks, HP uses a variety of strategies and tools, which can involve: advocacy, community mobilisation, interactive education and learning, behavioural change communication, participatory research, market-based approaches and peoplcentred design. The 2018 edition of the Sphere handbook makes clear that community engagement is central to all WASH interventions, including HP. The crucial elements of community engagement are shown in Figure 5. To ensure these are met, water supply interventions should always be undertaken with the corresponding community engagement measures. HP should recognise the differences within any population and aim to respond in various ways to the different WASH needs of women, men, girls and boys of different ages from different backgrounds, with different cultural and social norms, beliefs, religions, needs, abilities, health conditions, gender identities, levels of selfconfidence and self-efficacy, etc. (see X.15).
In an emergency, community structures and cohesion may become disrupted, and people will often be traumatised and grieving for the loss of loved ones. Hygiene promoters working with community members must be sensitive to this, and at first may need to simply listen to people to understand their experience and develop trust. There will almost always be members of the affected community who are keen to engage immediately and who can support the process of ensuring there is equitable access to a safe water supply and improved hygiene. By involving people in decisions regarding the water supply, the intervention can help to restore people’s dignity and strengthen their capacity to take ownership and action and improve their own situation. Community engagement can ensure that water facilities are well managed, maintained and accessible for everyone. Different degrees of participation (information, consultation, collaboration or delegation of power) may be possible at different times in the emergency, but there will always be space for some level of consultation.
It is vital to try to understand the affected community’s different perspectives on water supply (involving all relevant user groups), including how it will be effectively used and managed, and to involve them in decisions about the programme.
1. Listen and ask: It is vital to learn about water use and related hygiene practices and norms. For example: How do different people usually collect, store and use water? What is happening now and what has changed as a result of the emergency? What do different people need and want, to ensure that water facilities are effective and have a positive impact on health? What are the priority water-related risks? Who are the most vulnerable and what support do they need to access water facilities? Who can help from the affected population (and who has the requisite skills and capacities), local agencies or government departments? It is important not to treat everyone the same and to identify different groups to work with, such as youth, mothers and fathers of young children, religious leaders, primary school children, canteen workers, hairdressers, people with disabilities, etc. See also cross-cutting chapters on inclusive and equitable design X.15 and assessment of the initial situation X.1 X.2 X.3 X.4.
2. Involve and enable action: Interactive discussions can support different user groups to identify what they can do immediately to improve health and hygiene. It is important to find out what is potentially stopping them from acting (the barriers and obstacles to improved hygiene) and to find out what help they need, if any. By conducting surveys and differentiating between doers and nondoers, users and non-users of facilities, the drivers that motivate action can be identified. Supporting community organisation and civil society structures is also useful and can ensure that people motivate each other. A variety of interventions can help respond to the immediate risks, but the actual interventions used will depend on the context, such as interim water supply solutions like household water treatment and safe storage, the provision/cleaning of water collection and storage vessels and the provision of laundry facilities. Consider how water facilities will be maintained from the beginning and the community’s involvement in this, such as through the formation of committees or user groups.
3. Focus on vulnerability: People with specific needs (e.g. women and girls, elderly and people with disabilities) must be identified and their needs for adequate and equitable access to water ensured (e.g. for menstrual hygiene management). Ensuring women are on the response team is essential and ongoing outreach to women and girls is essential. Women and children are often responsible for collecting water in many communities, so discussions with them are crucial to ensure safety and access, such as by locating taps within reach and installing pumps that can be used with ease. Working with local organisations representing vulnerable groups, such as disabled people, is also important and essential. See also cross-cutting chapters on inclusive and equitable design X.15 and assessment of the initial situation X.1 X.2 X.3 X.4.
4. Plan together: Setting practical objectives and indicators and compiling a WASH strategy with others involved in the WASH response are key processes in an HP intervention. In this process, the ‘doable’ actions that can impact hygiene should be identified, and the monitoring of the impact of these actions must be defined. The affected community should contribute to this strategy. The recruitment, training and support of existing and new team members will help to ensure that plans come to fruition.
5. Collaborate and coordinate to implement: A variety of methods and tools can be used with different groups to motivate action to improve and effectively use and maintain water facilities and services for women and men, people in different age groups and with different abilities. Working closely with others involved in the response, especially the government, local authorities and other sectors, is also important. To minimise duplication and increase the efficient use of resources, the sharing of plans and ideas should be coordinated. It should be possible to undertake joint activities, such as assessments or evaluations, or HP outreach workers can focus on other priority health issues as well as hygiene.
6. Monitor and review: Through observation (are all people able to use the facilities safely, effectively and without waste?) and surveys (did people change their behaviour?), the effectiveness of HP and behavioural change efforts can be monitored. Continually seeking feedback from the population will enable adaptations in programming and improve effectiveness. It is also important to keep track of any rumours that might be detrimental and to respond to these as soon as possible, such as by incorporating them into discussions with community groups or providing information on social media.
Interactive methods: Methods that encourage dialogue and group discussion, such as ‘community mapping’ and ‘three-pile sorting’ using pictures and visual representations, require the active participation of community members and are usually more effective than just ‘disseminating messages’, as the latter erroneously assumes that people will passively internalise and act upon the information provided.
Access to hygiene, water supply items and infrastructure: It is important to consider the different needs of groups such as men, women, boys, girls or people with disabilities. For example, women and adolescent girls will often need support with managing menstruation, and consultation on this should be included in any water and hygiene programme. It is also important to note that hygiene promotion methods and access to WASH infrastructure go hand-in-hand, as hygiene promotion will not be effective without the appropriate infrastructure required for the desired behaviours.
In recent years, there has been a significant amount of work on trying to understand different influences on hygiene behaviour. It is clear that knowledge of germs and the transmission of disease is often insufficient and inadequate to change behaviour. The following suggestions can help make programmes more effective:
1. Make the practice (e.g. water treatment, water conservation, handwashing) easy and attractive: Products and supplies (e.g. a handwashing station with soap and water) should be easily accessible in each location where the desired behaviour should take place. Emphasising convenience and ease (small, immediate, doable actions) is often more effective at promoting behavioural change than focussing on the ‘ideal’ behaviour. Rewards and incentives, such as competitions, should be considered, and it is useful to find ways to attract attention, such as painting colourful latrine doors or installing handwashing facilities with mirrors.
2. Consider when people are likely to be most receptive: Disruption in context, such as that associated with most emergencies, or significant life changes, such as giving birth, may provide a window of opportunity for shifts in habit, because people become more mindful of what they are doing. Linking the desired behaviour to an existing habit is also more likely to succeed. For example, encourage handwashing at the same time as behaviours associated with infant care, such as feeding or nappy changing.
3. Draw on social norms and motivations: Psychosocial approaches to behavioural change have shown that it has many drivers and that behavioural change techniques should be applied according to these. To change health risk perceptions, personal information about these risks should be delivered. To change attitudes, beliefs about costs and benefits of a behaviour should be discussed. Appealing to people’s sense of disgust, nurturing behaviours and affiliation with a group can change emotional components of behaviours and motivate action. To change perceived norms, it is useful to convey the idea that most people perform the desired behaviour. Identify what people perceive others will think of them if they engage in the practice and try to change this perception if required. People can be encouraged to make public commitments to washing hands, using the water treatment facilities or supporting others in managing water supplies, with a focus on groups and communities instead of just on individuals. To change perceived abilities to perform a behaviour, one might demonstrate the behaviour and prompt behavioural practice. To foster behavioural realisation (self-regulation), action and barrier planning is vital, but memory aids are also useful for remembering the behaviour in key situations (e.g. handwashing before touching food). Community approaches, such as Community Health Clubs, have been found to be effective at promoting hygiene, and other strategies, such as behaviour-centred design and in-depth assessments of motivation, are worth exploring.
4. Encourage the habit: The promotion of the habitual behaviour through use of cues (nudges), such as footsteps leading to the handwashing facility, can be considered. In addition, behavioural trials may be useful wherein, for example, people may be asked to use soap or a handwashing facility for two weeks to be later interviewed about their experiences. Games with children can also help internalise the link between handwashing and germs.
Several reports, reviews and guidelines have observed the following weaknesses in hygiene promotion programmes:
Davis Jr., Thomas P. (2010): Barrier Analysis Facilitator’s Guide: A Tool for Improving Behaviour Change Communication in Child Survival and Community Development Programmes ood for the Hungry/Core Group, Washington D.C. USA
Ferron, S., Morgan, J., O’Reilly, M. (2007): Hygiene Promotion: A Practical Manual for Relief and Development ITDG Publishing, Rugby. UK