Innovative Approaches for Integrating Hygiene Promotion Into Water

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					            Innovative Approaches for
Integrating Hygiene Promotion Into Water Supply
             and Sanitation Programs




            Eckhard Kleinau, DrPH, MD
                 ENVIRONMENTAL HEALTH PROJECT
                 Objectives


• Explain the importance of integrating hygiene
  promotion into WSS – and health – programs:
  Hygiene Improvement Framework

• Present Hygiene Behavior-centered
  Programming process
  – Dominican Republic
  – Democratic Republic of Congo


• Discuss lessons learned, issues and
  challenges

                  ENVIRONMENTAL HEALTH PROJECT
Scientific Evidence of High Health Impact




                ENVIRONMENTAL HEALTH PROJECT
 Scientific Evidence of High Health Impact

  Hygiene Promotion                                            Hardware
           Handwashing
                                                         Excreta Disposal
Feces disposal, especially                                  Facilities
   for children under 3
                                                           Water Quantity
    Safe water handling
        and storage                                         Water Quality



 Diarrhea morbidity reduced by about                                        ?
Source: Esrey et al. 1991; Hutley et al. 1997.
                                      ENVIRONMENTAL HEALTH PROJECT
                                                  HYGIENE IMPROVEMENT FRAMEWORK
 Hygiene                              Access to
Promotion                            Technology



        Hygiene Improvement
     Diarrheal Disease Prevention




             Enabling
            Environment

            ENVIRONMENTAL HEALTH PROJECT
                                                                                                 HYGIENE IMPROVEMENT FRAMEWORK
            Behavior-centered Programming                               Improved Water Supply
 Hygiene    to achieve behavior/social change      Access to
Promotion                                         Technology            Improved Sanitation
            Communication methods
                                                                        Household Technologies
            Social mobilization
                                                                        – Soap
            Community participation                                     – Water containers
            Early adopters/Innovators                                   – Chlorine solution
            School sanitation & hygiene                                 Social marketing



                             Hygiene Improvement
                       Diarrheal Disease Prevention



                                          Policy improvement
                    Enabling
                   Environment            Institutional strengthening
                                          Community organization
                                          Financing and cost-recovery
                                          Multi-sectoral coordination & PPP
                                          Monitoring and evaluation
                                   ENVIRONMENTAL HEALTH PROJECT
  Hygiene Behavior-centered Programming
                What is it?

ü A systematic process for changing hygiene behaviors

ü Based on a comprehensive strategy

ü An action-learning approach

ü Uses existing methods and tools

ü Flexible and adapts to local situation

ü Helps program managers to plan hygiene promotion

ü Provides implementers with concrete skills

                     ENVIRONMENTAL HEALTH PROJECT
Hygiene Behavior-centered Programming
            What is it not?



           • Not a “silver bullet”



           • Not a blueprint



           • Not a tool



               ENVIRONMENTAL HEALTH PROJECT
 Hygiene Behavior-centered Programming
              Basic Steps

1. Establishing the diarrheal
   disease prevention rationale
2. Formative research to
   understand current practices
   and barriers to change
3. Analysis and development
   of behavior change approach
                           c
4. Trials of improved practices
5. Messages and materials development
6. Implementation, monitoring and evaluation
                    ENVIRONMENTAL HEALTH PROJECT
          Trials of Improved Practices

1. Training field personnel
2. Recruiting participants
3. An initial visit to gather background information,
   conduct hygiene behavior assessment
4. Debriefing to analyze information, prepare for counseling
5. Counseling visit to present options, get reactions,
   negotiate trial practices
6. Debriefing to discuss reactions to recommendations and
   options selected
7. Follow-up visits to learn about the reactions to the new
   practices
8. Analysis, summary, and application of results
                      ENVIRONMENTAL HEALTH PROJECT
      What Kind of Skills are Needed?


• Planning & design a communications strategy
• Formative research
• Communication
    – Interpersonal/Counseling
    – Social media
    – Mass media
•   Participatory training
•   Community organization
•   Social mobilization
•   Monitoring techniques

                     ENVIRONMENTAL HEALTH PROJECT
Hygiene Promotion: Dominican Republic

•   Where: 9 communities in Hato Mayor
•   When: 2000 – to date
•   How: 2 NGOs (MUDE, CRS), 23 promoters
•   Multi-sector:                                   Hato
                                                    Mayor
    – National Sewer and
      Water Authority (INAPA)
    – Ministry of Health and
      Social Welfare
    – PAHO
    – Peace Corps
• Experience helped to develop the hygiene
  behavior-centered programming approach

                     ENVIRONMENTAL HEALTH PROJECT
Behaviors Targeted in the DR

                                        BLèFU
        • Safe storage of drinking water
          (covered)                 41è92%

        • Handwashing at critical times:
          - after using the latrine 52è66%

        • Permanent place for
          handwashing                   18è38%



         ENVIRONMENTAL HEALTH PROJECT
      Dominican Republic Success


• Going to scale nationally
  – Communications materials
    adopted by MOH&SW
  – NGO and PAHO funding


• A regional model in LAC
  – Application of approach
    in Nicaragua and Peru
  – DR trainers provide
    technical assistance


                   ENVIRONMENTAL HEALTH PROJECT
 Democratic Republic of Congo (rural)

• At scale from start: Integrates hygiene
  improvement into primary health care
• Combines hardware and software,
  but different agents are responsible
   – Public Health sector
   – Local government
• Community agents and
  organizations play a critical role
• Few resources and skills: streamlined hygiene
  behavior-centered programming process
   – Initial focus on handwashing, other behaviors later
   – No trials of improved practices
                     ENVIRONMENTAL HEALTH PROJECT
          Monitoring and Evaluation

• Participatory community
  monitoring
  – Helping communities to
    measure progress and
    take action

• Quantitative evaluation
  of effectiveness
  – Hygiene improvement

• Impact evaluation of
  health outcomes
  – Prevalence of diarrhea (and intestinal parasites)

                      ENVIRONMENTAL HEALTH PROJECT
           Key Success Factors

• Hygiene promotion already addressed in the
  planning stage of WSS, not an afterthought
• Systematic implementation of an entire
  process, not just individual steps
• Community participation
  – “hygiene promotion is something
    you do with people, not to them”

• Relying on existing resources
• Multi-sector approach to institutional
  collaboration and coordination
• Monitoring and documentation of results
                   ENVIRONMENTAL HEALTH PROJECT
                    Challenges

• Scaling-up hygiene promotion
  – Democratic Republic of Congo
• Sustaining health impact (MDG)
  – Dominican Republic
• Institutionalizing hygiene promotion & capacity
  – DRC and DR
• Institutions as role models
  –   Schools
  –   Health facilities
  –   Social centers
  –   (e.g., Anganwad in India)


                      ENVIRONMENTAL HEALTH PROJECT
Thank You
ENVIRONMENTAL HEALTH PROJECT
       Who Does Hygiene Promotion?

•   Public health system
•   Social services
•   Education sector
•   NGOs
•   Community groups

• Private commercial sector
    – Soap manufacturers (Handwashing Partnership)


• Less frequently: WSS technicians/engineers

                    ENVIRONMENTAL HEALTH PROJECT
             • Coverage:                                             • Behavioral/Social
             –Safe Water                                               Change:
 Access to   –Sanitation                            Hygiene
Technology                                         Promotion –Children’s feces disposal
                                                             –Handwashing place
             • Access:                                       –Handwashing practice
             –Continuity                                     –Water storage and
             –Distance/Time                                   treatment at home
             –Quality                                        –School sanit. & hygiene
             –Minimum standards                              –Qualitative assessments




                 Diarrheal Disease Prevention



                                          • Sanitation Policy Assessment

         Enabling Environments            • Community Monitoring
                                            and Participatory Planning
                                          • Institutional Capacity
                                            Assessment


                                  ENVIRONMENTAL HEALTH PROJECT
      Why is Hygiene Promotion an Important
         Component of WSS Programs?

     • Access to sufficient & safe water and improved
       sanitation are linked to sustainable livelihood

     BUT …

     • To maximize health impact, hygiene behaviors
       need to improve together with hardware

                Millennium Development Goals:
••   Access to improved water
     Access to improved water                          •• Reduce Child
                                                          Reduce Child
••   Access to improved sanitation                        Mortality
                                                          Mortality
     Access to improved sanitation
                        ENVIRONMENTAL HEALTH PROJECT
 Scientific Evidence: Diarrhea Reduction
Through Hardware and Hygiene Promotion


                               sal
                         is po
                    eta D lities
                Excr Faci
 Intervention




                              ty
                           nti
                         ua
                   terQ
                 Wa
                             lity
                         Qua
                     ter
                  Wa

                          ing
                        sh
                      wa
                    nd
                  Ha
                                     0           10               20    30   40

                                             Median reduction (%)
Source: Esrey et al. 1991; Hutley et al. 1997.
                                         ENVIRONMENTAL HEALTH PROJECT
        Examples from the DR and DRC

 Hygiene    • Handwashing                      Access to      • Water source
Promotion                                     Technology        improvement and
            • Feces disposal                                    construction
            • Point-of-use water                              • Latrine construction
              storage and chlorination
                                                              • Social marketing




                    Diarrheal Disease Prevalence

                             • Local government as coordinator
                  Enabling   • Community committees
                 Environment • Community labor, user fees,
                               subsidized materials
                             • Water NGO does hardware,
                               Health NGO does software
                             • Pre-post evaluation of impact
                               ENVIRONMENTAL HEALTH PROJECT
    Democratic Republic of Congo (urban)



• Not sure about using this, hygiene behavior-
  centered programming was not followed

•   Hardware combined with software
•   Focus on major markets
•   WSS services sustained through fees
•   Behavior change observed after a short period
•   Pre-post assessment


                   ENVIRONMENTAL HEALTH PROJECT
Can Software be Done Without Hardware?



• Yes, it has been done successfully, but …

• Programs are more effective, if software is
  done together with hardware, especially when:
  – Water quantity is insufficient to meet minimum daily
    requirements per person
  – Water is contaminated at the household
  – Latrines do not exist to dispose feces
  – People have no soap for washing hands



                    ENVIRONMENTAL HEALTH PROJECT
Hygiene Behaviors with High Health Impact



 • Handwashing

 • Feces disposal, especially for children under 3

 • Safe water handling and storage

   Protecting food from contamination




                      ENVIRONMENTAL HEALTH PROJECT

				
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