Effective hygiene promotion works – right?

Many people, especially children, are still becoming ill and even dying due to unsafe hygienic behaviour. Good behaviour – using a hygienic toilet, washing hands with soap, safely managing drinking water – are typical behaviours resulting from effective water, sanitation and hygiene (WASH) programmes.

Effective hygiene programmes, what does that mean? How is effectiveness translated into hygiene programmes in the WASH sector? Are there key principles that all programmes should practice if they want to be effective? What is known to work in all circumstances?

Let’s try to identify on what grounds the sector calls a programme effective. To find out what important players in the field of hygiene promotion say, we did a quick scan of ten review papers of hygiene promotion programmes by seven leading sector organisations: the London School of Hygiene and Tropical Medicine, WaterAid, UNICEF, WHO, WSP, the Water and Sanitation Collaborative Council and our own organisation: IRC International Water and Sanitation Centre.

We came up with five general programme principles:

1. Political will and support
Political will is crucial for success. Obviously political will alone does not make it work, but it is a sign of political support for undertaking hygiene promotion programmes. To be successful, a hygiene promotion programme also needs to be well coordinated and operate through cooperation and partnerships. Shordt (2003) reviewed 52 references in which more than 50 hand washing programmes were described and found that “many of the successful programmes were mounted through collaboration with health departments, local government and civil society. Inter-agency cooperation appears to be a key to effective programming”

2. Own plans and budgets
While an obvious need, in real life it is not always common practice for hygiene interventions to have their own plans, budgets, research, monitoring and staff (or human resources allocated from the programme into which hygiene promotion is integrated). Good hygiene plans also include formative research to determine key behaviours to focus on, and have or develop behavioural change communication strategies. More on these planning principles can be found in the programming guidance document of the Water Supply and Sanitation Collaborative Council.

3. High user needs or interests
Thirdly, a hygiene programme should be wanted by the target groups. Here demand assessment and creation come in. Before implementing a programme or activity, there must be arequest from the population, a specific group or the local authorities. Users must also find programmes relevant and applicable.

4. Repeated interventions are a “must”
After comparing the outcomes of about 100 studies on the effectiveness of hygiene promotion programmes, Cairncross and Valdmanis conclude:  “It is likely that hygiene promotion activities need to be repeated from time to time — say, every five years — but are not required on a continuous basis”.  Shordt and Cairncross indicate that hygiene interventions should last more than one year, and/or beyond the time of physical implementation of water points or latrines (when part of a broader water or sanitation programme). Too often, once construction is complete, the communities and households are left alone.

5. Include audience research and targeting
“Finding out what messages are best for which groups helps design better programmes” say Appleton and Sijbesma in their thematic overview paper on hygiene promotion. Doing so is easier said than done though. Finding out what really motivates or prevents different categories of people to adopt safe hygiene practices and translating these into a hygiene promotion programme is an art in itself. Luckily we are learning more about hygiene behaviour triggers and barriers and how to address them in programmes.

So what? We know more of what works. But how do we measure effectiveness?

According to the reviewed publications, using these five principles will mean greater success in achieving sustained improved hygiene behaviours. What is the validity of these principles in practice? Are they indeed sufficient together for effective programmes? Could they be considered as key indicators? How do we measure their effectiveness in the field?

Knowing what works is a first step for action research on measuring the effectiveness of hygiene interventions and collecting and analysing the involved costs. At the moment this is happening in three African countries: Ghana, Mozambique and Burkina Faso and also in Andhra Pradesh, India. More information on the methodology of this research can be found in WASHCost Working Paper 6 and the upcoming Working Paper 7 to be published on the WASHCost working paper pages.

We’d love to hear from you
Do you have similar experiences? Or have you found more or other principles important? We hope this post will encourage you to reflect on the successes or failures of hygiene interventions and to share your thoughts and experiences. We would love to hear from you!

Contact: Amélie Dubé, dube@irc.nl and Ingeborg Krukkert, Krukkert@irc.nl
IRC International Water and Sanitation Centre

See “Reference List : Effective hygiene promotion – blog article 2012” for a list of all documents referred to in this article with links to the full text documents.