World Bank

Excerpts from the document

After years of debate, most people working in water and sanitation now agree that hygiene promotion is vitally important. But even now, many programmes and projects either ignore it or do it badly.

This Field Note describes two African hygiene promotion programmes that have successfully used new approaches: Programme Saniya in Burkina Faso, and ZimAHEAD in Zimbabwe. They both concentrated on understanding how people actually behave and hence how to change that behaviour, and they both demonstrated ideas that can be applied at a larger scale.

Changing human hygiene behaviour is a long process that is difficult to measure, and both of these programmes still have obstacles to overcome. However, this work indicates that systematic and carefully managed hygiene promotion programmes can achieve improvements in hygiene behaviour and hence reduction in diarrhoeal diseases.

Diarrhoeal diseases are still a leading cause of mortality and morbidity in children under five. Each child in Africa has an estimated five episodes of diarrhoea per year and approximately 800,000 African children die each year from diarrhoea and dehydration. Hygiene improvement on a huge scale is urgently needed, to reduce this burden of disease and to maximise the health benefits of water and sanitation interventions.

Public health professionals have tried various approaches to reduce diarrhoeal diseases. In the 1980s major investments aimed to improve the coverage of drinking water and sanitation facilities. However, evidence collected over the past decade shows that changes in hygiene behaviour significantly augment the health benefits that arise from drinking water and sanitation projects. The principle is therefore well established that hygiene promotion should play a part in water and sanitation programmes. In practice, programmes have found it hard to achieve good results for a number of reasons:

• Engineering programmes do not naturally lend themselves to the methods and timescales that hygiene promotion requires.
• Hygiene professionals have been hard to find, and old-fashioned didactic approaches based on education about germ theory and threat of disease have been the norm.
• Though some programmes have undoubtedly been successful in changing hygiene behaviour, such private practices are hard to measure and so results have often been unconvincing.

It has become clear that hygiene promotion programmes should focus their efforts on producing real and measurable change in key hygiene behaviours. This Field Note describes two such programmes that appear to have had positive results within a reasonable timescale:

• Programme Saniya in Burkina Faso, which demonstrates the role of formative research
• The ZimAHEAD Community Health Clubs in Zimbabwe, which institutionalise the process of behaviour change

Programme Saniya was carried out in Bobo-Dioulasso between August 1995 and July 1998. The programme was implemented by the Ministry of Health of Burkina Faso with technical assistance from the London School of Hygiene and Tropical Medicine (LSHTM) and funded by the United Nations Children’s Fund (UNICEF). It aimed to promote a small number of safe hygiene practices, was based on the existing local motivation for hygiene, and used local channels of communication to reach the target groups.

The programme used focus-group discussions and a small questionnaire survey to identify local channels of communication suitable for specific target groups. Although two-thirds of mothers regularly listened to local radio, the programme staff decided that face-to-face domestic visits would also be needed, because other people who cared for children had little exposure to any type of communication except word of mouth. Messages were also transmitted during a ‘djandjoba’ (social event with music and dancing), which provided a good environment for disseminating them.

Zimbabwe Applied Health Education and Development (ZimAHEAD) is a Zimbabwean NGO that has pioneered an innovative methodology to mobilise rural people through the establishment of Community Health Clubs. A Community Health Club (CHC) is a voluntary community based organisation formed to improve family health in each village. It is open to men and women of all ages, educational levels and religions, and ideally includes as many villagers as possible. In 1994, the CHC concept was tried out in a small field study in which twelve clubs were established and monitored during six months of training in two wards of Makoni District, in Zimbabwe.

The uptake was good and it was further expanded into a pilot project in 1996/97. In 1998 ZimAHEAD was founded to enable the approach to be implemented on a larger scale. By 2000, the CHC approach had the potential to expand into a national programme. There were 350 clubs and over 20,000 beneficiaries in Z i m A H E A D project areas, and training was also being provided to other agencies to set up a further 150 clubs. However, the political situation in Zimbabwe deteriorated to such an extent that all major funding agencies felt obliged to withdraw governmental support. Meanwhile, the replicability of the approach is indicated by the fact that CHCs have also been established in a pilot project in rural areas of Sierra Leone.

The following principles guide ZimAHEAD’s CHC approach:

• Health education, hygiene promotion and advocacy should be integral components of an holistic approach to development.
• People respond positively when they clearly understand and direct their own change.
• Engendering a ‘common unity’ of purpose is a vital first element of community mobilisation.

The project involves retraining Ministry of Health Environmental Health Technicians (EHTs) in the CHC methodology and the use of Participatory Hygiene and Sanitation Transformation (PHAST) training materials. The CHC system is participatory by nature, and its structured programme enables behaviour change to be monitored and health awareness measured.

Lessons from programme Saniya and ZimAHEAD

The two programmes used different methods and different words to describe their work, but they both promoted hygiene through understanding and changing people's behaviour. A common set of lessons emerges from the two programmes:

• Hygiene promotion programmes should address behaviour change systematically and should focus on the changes that are needed. The key to changing behaviour is first to understand what drives and motivates it. This issue is far more complex than was once thought. Behaviour change is difficult to achieve and requires considerable resources.
• Communities are not passive recipients of hygiene education. They are active partners and should be consulted and involved in a systematic manner. Programmes that conform to existing cultural patterns tend to be more successful than those that do not.
• Changes in hygiene behaviour are difficult to assess but structured observation using clearly defined criteria seems to give the most accurate results.
• Although quantifying behavioural changes and cost effectiveness in hygiene programmes is extremely difficult, it can provide information which is vital to the structuring – and funding – of future programmes.
• The evidence of Programme Saniya and ZimAHEAD suggests that building such programmes to scale depends on several factors:
  
  • Tangible results emanating from a carefully constructed local pilot project
  • Community motivation based on perceived social and economic benefit
  • Integration of the programme with government health administration
  • Establishment of a committed NGO to direct the process of expansion

WSP website on August 17 2006.