Accelerating and sustaining behaviour change: New handbook launched at GSF learning event

This week, the Global Sanitation Fund (GSF) and the GSF-funded ‘Fonds d’Appui pour l’Assainissement’ (FAA) in Madagascar launched a new handbook on accelerating and sustaining the end of open defecation.

The handbook was launched during the GSF Learning Event in Antananarivo, Madagascar, inaugurated by Madagascar’s Minister of Water Sanitation and Hygiene, Roland Ravatomanga.

A community celebrating the creation of their ‘model latrine’ for others to replicate during a FUM session in Madagascar. Credit: WSSCC

The ‘Follow-up MANDONA’ (FUM) handbook is a field guide for practitioners of Community-Led Total Sanitation (CLTS) – an empowering approach for improving sanitation and hygiene through collective behaviour change, rather than external subsidies or prescription. FUM aims to systematically engage communities after they have been initially ‘triggered’ and committed to ending open defecation.

‘Mandona’ is a Malagasy word which means ‘to push’. FUM brings the entire community together for a self-analysis of their sanitation situation, which then helps them immediately create models that prevent the ingestion of faeces. The approach harnesses the power of Natural Leaders to replicate these models across the community, which includes helping those that are least able, in order to advance to ODF status. By focusing on sustainable behaviour change, FUM is also a useful tool for addressing issues surrounding ‘slippage’, which relates to returning to previous unhygienic behaviours.

FUM was developed and refined by MIARINTSOA NGO, a sub-grantee of the FAA programme. Given the success of FUM in Madagascar and elsewhere, the GSF and FAA created the FUM handbook to provide a practical guide for how CLTS practitioners can implement the approach in their own contexts.

Download ‘Follow-up MANDONA: A field guide for accelerating and sustaining open defecation free communities’ (English/French)

The weeklong global event where the handbook was launched brings together implementing partners, WASH experts, and high-level government representatives from GSF-supported programmes. These actors are exchanging ideas and sharing best practices for achieving improved sanitation and hygiene behaviour at scale.

During the launch, WSSCC Executive Director Chris Williams highlighted how FUM is engraining the sustainability of sanitation and hygiene behaviour change in Madagascar and beyond. “Once a village, or an entire commune, has reached ODF status, the story isn’t over. In fact, the work continues. This important publication documents the innovations that Madagascar has put together to systematically follow-up with villages. FUM aims to ensure that the change in attitudes and creation of convictions that my ‘sanitation problem is your sanitation problem’ – ‘or my shit is your shit’ – is dealt with as a collective community effort.”

WSSCC Executive Director holds up the Follow-up MANDONA handbook at GSF Learning Event opening ceremony. Credit: WSSCC/Okechukwu Umelo

FUM has become one of FAA’s most important tools for empowering over 1.6 million people to live in open defecation free environments on their own terms. Due to its success in Madagascar, FUM has recently become a core strategy for national sanitation and hygiene programmes in Uganda, Nigeria, Benin, and Togo.

Community members in Nigeria agreeing to trigger their neighbours and help those who don’t have the means to build their own latrine. Credit: WSSCC

Kamal Kar, the Chairman of the CLTS Foundation, which has extensively supported the FAA programme to develop their CLTS approach, emphasized the importance of the handbook in sharing proven approaches to practitioners around the world: “I am glad that the Malagasy NGO, MIARINTSOA, with the help of the FAA programme, WSSCC and the GSF, has systematically documented their experience of post-triggering follow-up from their implementation of CLTS over the last 4-5 years. Publication of this Follow-up MANDONA handbook is indeed a step forward towards country-wide scaling up of good practice of CLTS in Madagascar and beyond.”

Eugène De Ligori Rasamoelina, Executive Director of MIARINTSOA NGO, which developed and refined Follow-up MANDONA. Credit: WSSCC

“I must say that the emergence of thousands of ODF villages in Madagascar, starting with my multiple support visits to the country since 2010 to strengthen the approach, is a brilliant example of quality CLTS implementation with its central philosophy of local empowerment. I believe that this handbook will be useful in understanding and ensuring post-triggering follow-up in CLTS for sustained behaviour change.”

Find out more about the Global Sanitation Fund on the WSSCC website.

Impact of WASH in improving health of school children reviewed

More attention should be given to the assessment of nutrition practices when assessing the impact of WASH on the health of school children. We also don’t know enough about the long term impact of WASH interventions on child health. These are some of the conclusions that researchers from the Center for Global Health and Development at the the University of Nebraska Medical Center (UNMC) drew from a review of the literature [1].

Dr. Ashish Joshi and research assistant Chioma Amadi reviewed the impact of water treatment, hygiene, and sanitary interventions on improving child health outcomes such as absenteeism, infections, knowledge, attitudes, and practices and adoption of point-of-use water treatment.  For their final analysis they selected 15 peer-reviewed English-language studies published between 2009 and 2012 that focused on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children.

Cricket legend Sachin Tendulkar UNICEF ambassador for hygiene & sanitation in South Asia

Recently-retired Indian cricket legend SachinTendulkar has become UNICEF Ambassador for South Asia to promote hygiene and sanitation in the region over the next two years.

“I was disheartened to know was that 1600 children die everyday because of diarrhoeal infected diseases”, Tendulkar said at a press conference on 28 November in Mumbai. “I just want to help UNICEF to make more people aware of this initiative that I am part of. It is as simple as washing your hands with soap”.

A video compilation highlights Tendulkar’s involvement in UNICEF campaigns over the past ten years on issues including polio, HIV/AIDS and handwashing.

Source: UNICEF, 28 Nov 2013 ; Times of India, 28 Nov 2013

“We Can’t Wait”, say WSSCC, Unilever and WaterAid on World Toilet Day

We Can’t Wait – Governments, civil society and business should work together to tackle sanitation for women’s health; say Water Supply and Sanitation Collaborative Council, Unilever and WaterAid

Dowwload the report here. 

A collaborative approach between governments, civil society and business is essential to getting the Millennium Development Goal sanitation target back on track. This is critical to improve the health and prosperity of women worldwide, says a new report jointly published by the United Nations hosted organisation Water Supply and Sanitation Collaborative Council, international development organisation WaterAid and Unilever’s leading toilet brand Domestos.

The report, We Can’t Wait, was presented today at a UN event in New York which celebrates recognition of the first official World Toilet Day. The day serves to remind the world that over 2.5 billion people lack access to an adequate toilet, with devastating consequences in particular for the well-being, health, education and empowerment of women and girls worldwide.

Why World Toilet Day 2013 matters: unblocking constipated progress on sanitation

Why World Toilet Day 2013 matters: unblocking constipated progress on sanitation

Author: Julian Doczi, Research Officer – Water Policy, Overseas Development Institute (ODI), London, UK, j.doczi@odi.org.uk

A few months ago, the sanitation world received a welcome boost when the UN General Assembly officially recognised World Toilet Day. Founded in 2001 by popular sanitation advocate Jack Sim, and celebrated on November 19 each year, this Day aims to draw attention to the global sanitation crisis via the toilet, a topic which causes discomfort or giggles for many. Indeed, the Day has always had both a fun and serious side, with healthy doses of toilet humour running alongside the sobering headline that 2.5 billion people worldwide still lack access to improved sanitation. But its formal recognition this year is an important milestone, and one of several recent developments that could mark the beginning of a real sea change in political momentum toward the achievement of decent sanitation for all. 

There is still a long way to go. Poor sanitation exacts a huge human burden and costs the global economy over US$260 billion per year, with health, education, personal security, human dignity, and the environment all affected. While sector specialists have long recognised these impacts, skewed heavily towards women and children, ministries and politicians have often preferred to look away.  In the first iteration of the Millennium Development Goals (MDGs) in 2000, sanitation was ignored completely, and was included only as an afterthought in 2002. Afterthought or not though, the target – to reduce by half the proportion of people without sustainable access to  safe drinking water and basic sanitation by 2015 – has stimulated a healthier public and political debate, though progress is still slow. While the world has already met the drinking water target, it remains off-track for the sanitation target, with rural dwellers and the urban poor lagging most.

From the MDG target came further breakthroughs. The focus on water and sanitation in the 2006 Human Development Report was a timely reminder of the link between poor sanitation and poverty, and was followed by the UN General Assembly’s declaration of 2008 as the International Year of Sanitation. Evidence suggests that this event galvanised a new surge of activity on sanitation that has continued to this day. Rose George’s widely read book on sanitation, The Big Necessity, which looked at the many factors constraining sanitation progress, provides a useful reference point for assessing the level of progress over the last five years.

So what does this new surge of activity on sanitation look like, and who is championing the cause? Since 2008 we have seen:

• Matt Damon, Bono, Richard Branson and many others going on a ‘toilet strike‘ for sanitation earlier this year
• Unprecedented levels of investment in sanitation by donors like USAID (investing $1 billion USD in their new ‘Water and Development Strategy’ for 2013-2018), DFID (investing £104 million in their new ‘Water, Sanitation and Hygiene Results Programme’) and the Bill and Melinda Gates Foundation (investing at least $250 million USD in water, sanitation and hygiene initiatives since 2010, including their ‘Reinvent the Toilet Challenge’)
• Access to water and sanitation declared a fundamental human right by the UN General Assembly in 2010, affirmed by UN Human Rights Council, and now allowing citizens to legally demand these rights from their states
• Strong likelihood of an independent and more holistic goal (not just a single target) on ‘water and sanitation for all‘ in the Sustainable Development Goals set to succeed the MDGs in 2015, driven by strong advocacy and clear global demand
• The Sanitation and Water for All Partnership, established in 2010, consisting of high-level representatives from 44 developing country governments and a variety of development partners, meeting regularly to catalyse more political leadership and action on sanitation
• Major national campaigns for sanitation in many off-track countries, such as the recent ‘Nirmal Bharat Yatra‘ in India: a sanitation awareness and behaviour change ‘travelling carnival’ that directly reached over 160,000 attendees last year

and now:

• An official, UN-approved and permanent day for drawing attention to the sanitation crisis – World Toilet Day!

Have we now have reached a point of no return for sanitation? Big challenges remain, and the test will be progress on the ground, but the growing momentum can only be cause for optimism. World Toilet Day provides an opportunity for advocacy on sanitation at all levels, raising interest, helping to overcome shame and embarrassment, and stimulating investment. No longer is sanitation mainly an engineer’s domain either. The development community increasingly understands that the social and political incentives for sanitation decision making, among both politicians and citizens, are key to unblocking progress. This means that solutions are not straightforward, and points to new directions for engagement at the country level.

So congratulations to Jack Sim and all the other sanitation advocates as we take stock today, and remind ourselves of what still needs to be done. World Toilet Day is a clear sign that we’re moving in the right direction.

Sanergy from Nairobi wins first Sarphati Sanitation Award

Becky Auerbach (Sanergy). Photo: Dick de Jong, H2O Communications, 2013

Sanergy won the first Sarphati Santation Award because in the past two years it has built 242 sanitation facilities run by 130 local entrepreneurs from Nairobi’s slums, who earn US$ 2,000 per year in income for their families while providing hygienic sanitation to 10,000+ residents. The Mayor of Amsterdam awarded a cash prize of 50.000 euros (US$  67,000) and a statue by famous artist Marte Röling to the winner, Becky Auerbach from Sanergy during the International Water Week (IWW) in Amsterdam. IDE Cambodia and Mr. Toilet, Jack Sim were the runners up.

The three nominees have in common that they provide remarkable sustainable business solutions “turning shit into gold”. They have shown that it is very well possible to address sanitation and public health issues in developing countries while making profit. Over the past years interest has increased for new ways to address the Millennium Development Goal (MDG) for sanitation.

SuperAmma campaign for changing hand washing behavior

Launched by the London School of  Hygiene and Tropical Medicine and others the SuperAmma campaign is the culmination of years of behavioural science research to inculcate the habit of handwashing with soap. We designed a  communication campaign based on the Evo-Eco theory of behaviour change.

Here we make available the approach and the materials that worked successfully in Southern India to inspire and assist you in your behaviour change campaign.

• Link

WaterSHED – Microfinance boosts latrine purchases in rural Cambodia

Microfinance boosts latrine purchases in rural Cambodia | Source: WaterSHED, Sept 27, 2013 |

An innovative way to integrate micro-finance and sanitation marketing is resulting in a truly Hands-Off success story and helping to scale up access to safe toilets by the rural poor. 

Many proponents of market-based sanitation programs around the world are keen to explore financing as a way to make toilets more accessible to the rural poor. The most repeated complaint by rural villagers when discussing toilet adoption in Cambodia, like elsewhere, is aut louy or “no money”.

Cost is also one of the major roadblocks in offering sanitation financing: loan assessment, disbursement, and payment collections are expensive activities. Because loans for toilets are relatively small, the interest (even at high rates) is not likely to offset the operating costs of the micro-finance institution (MFI). Furthermore, MFIs typically prefer to offer ‘productive’ loans as a opposed to ‘consumptive’ ones because of their lower risk of delinquency or default (a loan to buy a sewing machine for a small business that will generate revenue to make payments as opposed to a loan to repair the roof of a house). Loans to purchase toilets and water filters are considered consumptive.

Annotated Bibliography of 2013 Handwashing Studies

An Annotated Bibliography of 2013 Handwashing Studies

This annotated bibliography was compiled by WASHplus and contains citations and abstracts to 20 peer-review handwashing studies that were published from January through September 2013. Links are also provided to the abstract or full-text for each article. Please email WASHplus if you have additional studies to include. 

JOURNAL ARTICLES, BY PUBLICATION DATE

SEPTEMBER 2013

1 — Handwashing before Food Preparation and Child Feeding: A Missed Opportunity for Hygiene Promotion. Am J Trop Med Hyg, Sep 2013. F Nizame. (Abstract)
From 50 randomly selected villages in Bangladesh, we collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program. Most participants cited the unavailability of soap and water near the cooking place as a barrier to handwashing before food preparation. Most caregivers ranked nurturing messages as the best motivator to encourage handwashing with soap.

2–Designing a Handwashing Station for Infrastructure-Restricted Communities in Bangladesh Using the Integrated Behavioural Model for Water, Sanitation and Hygiene Interventions (IBM-WASH). BMC Public Health, Sep 2013. K Hulland. (Full text)
Handwashing stations — a dedicated, convenient location where both soap and water are available for handwashing — are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal.

3–A Qualitative Evaluation of Hand Drying Practices among Kenyans. PLoS One, Sept 2013. B Person. (Full text)
Recommended disease prevention behaviors of hand washing, hygienic hand drying, and covering one’s mouth and nose in a hygienic manner when coughing and sneezing appear to be simple behaviors but continue to be a challenge to successfully promote and sustain worldwide. We conducted a qualitative inquiry to better understand current hand drying behaviors associated with activities of daily living, and mouth and nose covering practices, among Kenyans. We conducted 7 focus group discussions; 30 in-depth interviews; 10 structured household observations; and 75 structured observations in public venues in the urban area of Kisumu; rural communities surrounding Kisumu; and a peri-urban area outside Nairobi, Kenya. Using a grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes. Hand drying, specifically on a clean towel, was not a common practice among our participants. Most women dried their hands on their waist cloth, called a leso, or their clothes whether they were cooking, eating or cleaning the nose of a young child. If men dried their hands, they used their trousers or a handkerchief.

Designing a handwashing station for infrastructure-restricted communities in Bangladesh

Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC Public Health 2013, 13:877 doi:10.1186/1471-2458-13-877

• Full text

Kristyna RS Hulland, et al.

Background – In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations ? a dedicated, convenient location where both soap and water are available for handwashing ? are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour.

Methods – We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs.

Results – Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials.

Conclusions – A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.