Innovative approaches to sustain handwashing with soap and open defecation free status in rural communities in Tanzania

By SSH4A Tanzania

In Tanzania, SNV has developed, under the Sustainable Sanitation and Hygiene For All programme, two innovative approaches to sustain handwashing with soap and open defecation free status in rural communities. These are triggering with soap at vaccination centres and Jirani (neighbours) sanitation groups.

The first intervention consists of triggering at vaccination centres as they were found to be ideal places to raise awareness of the importance of washing hands with soap among pregnant women, mothers and other caregivers.

The second intervention is based on having neighbours who monitor the sanitation and hygiene progress of the households closest to their homes and sensitise other neighbours on the importance of building, taking care of, and improving sanitation and handwashing facilities.

The following case studies provide practical information for implementing the interventions, and brief discussions on the remaining challenges and lessons learned by the SNV team and their partners on the ground:

SSH4A Tanzania, 2019. Emotional demonstrations (emo-demos) of handwashing with soap at vaccination centres. Dar es Salaam, Tanzania: SNV Tanzania. 8 p. Download case study

SSH4A Tanzania, 2019. Jirani sanitation groups : sustaining open defecation free status in Tanzania. Dar es Salaam, Tanzania: SNV Tanzania Download case study

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A ‘Losing Prospect’ Argument for Changing Sanitation Behaviour

A ‘Losing Prospect’ Argument for Changing Sanitation Behaviour |

• Source/complete article & references: Nidi Khurana, End Poverty in South Asia – Jan 15, 2014.

Excerpts: 

• Fact #1: One in six people still defecate in the open.
• Fact #2: Most of them are not entirely convinced that a toilet does any good.
• Fact #3: Many of the recent toilet adopters still like to go in the open.
  

I don’t mean to be alarmist, but these signal a need for a shift in thinking about the complex problem of addressing behaviour change with respect to toilet adoption. 

With a myriad missing links to sustainable sanitation uptake, I’ll stick my neck out and say that the stickiest issue in sanitation today is not one of lack of investment, nor political commitment or markets. Clearly, the governments understand the wide-ranging impacts of sanitation on health, environment, and economy, and have committed billions of dollars to increasing sanitation coverage. Recently, the Government of India quadrupled its investment in rural sanitation in the current planning period (2012 – 2017) to US$ 6 billion through its ambitious Nirmal Bharat Abhiyan program. Moreover, there seems to be robust enthusiasm in the private sector for the ‘ready for take-off’sanitation market in low-and-middle income countries with low coverage. The continually baffling dilemma is in some ways an age-old one – that of changing mindsets.

Key hygiene behaviours for safe water and health on World Water Day

Alana Potter, lead author of the WASHCost working paper on “Assessing hygiene cost-effectiveness“, explains the importance of changing hygiene behaviours so that improved water and sanitation can lead to the expected health benefits. She has been reviewing indicators, tools and methods that sector institutions are using to monitor and measure hygiene behaviour change and identified three key hygiene behaviours common to all of these tools. Simply put, these are hand washing, using a toilet (i.e. separation of faeces from users) and safe management of household water. These are crucial for health benefits to be derived from improved water and should be remembered on World Water Day.

Interview and video by Nicolas Dickinson, IRC International Water and Sanitation Centre
March 21, 2012

Source: IRC / WASHCost, 21 Mar 2012

International hygiene study: scores for personal and household hygiene in 12 countries presented

In the wake of Global Handwashing Day, the Hygiene Council has released more findings from its international HABIT Study (Hygiene: Attitudes, Behavior, Insight and Traits). Below are charts comparing handwashing and household hygiene scores for 12 countries.

Percentage of respondents who wash hands 5+ times daily

Percentage with High Household Hygiene Score

UAE: Students learn good health goes hand in hand with hygiene

The results of the international Dettol HABIT Study (Hygiene: Attitudes, Behaviour, Insight and Traits) were recently presented to health and safety professionals by expert professors from the Global Hygiene Council in Dubai. During the symposium, the Dubai Ministry of Education invited a number of young school students to learn about the importance of hygiene.

Professor Tariq Madani of the King Abdulaziz University, Jeddah, held an interactive workshop for the children, which involved a demonstration of the Interactive ‘Glow germ Booth’.

The Dettol HABIT Study was carried out in 12 countries including Saudi Arabia and the UAE, the only countries where face-to-face interviews were conducted. The study found that people who have good manners have better personal hygiene and are almost two and a half times more likely to have good health with low levels of colds and diarrhoea.

West Africa: Stopping cholera emergencies

Cholera outbreaks in West Africa generally trigger extra hand-washings in households and panic-buying of bleach for treating water. But beating the deadly – but easily preventable – illness requires that such hygiene practices become routine, health experts say.

Researchers with the London School of Hygiene and Tropical Medicine (LSHTM) say knowing the drivers behind behaviour and tying hygiene messages to those impulses is crucial for preventing cholera, which has become a recurring health emergency in West Africa.

“If we want sustainable change we need to make sure people practice things so they become habits,” Jeroen Ensink of LSHTM’s environmental health group told IRIN.

One way for aid agencies to do so, he said, is to dissociate hygiene messages from cholera – which is seasonal – and link them instead to general diarrhoeal disease.

Ensink also said it might be time to “re-brand” hygiene and health messages, as knowledge of cholera’s causes does not always translate into new habits. “Hand-washing messages need not be just about health; they can be about: if you want to be modern, to smell nice, to be attractive to the opposite sex, use soap.” The use of proper latrines can be linked to privacy instead of just proper hygiene, he added.

LSHTM has studied the impact of government and aid agency prevention and preparedness measures in Guinea and Guinea-Bissau as part of a project funded by the European Commission humanitarian aid department (ECHO).

Coherent

The ECHO project aims to build a more coherent approach to cholera control with sound preparedness and early response. And ECHO says ‘quick impact’ actions in vulnerable communities should be accompanied by longer-term prevention measures.

To date, emergency and development strategies fail to address the disease properly, lacking common objectives and complementary actions, ECHO says.

ECHO is focusing on Guinea and Guinea-Bissau, where cholera has become endemic; during 2007 and 2008 over 23,000 people were infected and 560 died in the two countries.

But all of West Africa is highly vulnerable to cholera and a regional approach is needed; ECHO and its partners will study lessons from Guinea and Guinea-Bissau to see what might be applied more widely.

As part of the ECHO-funded project UN Children’s Fund and NGOs are training local health workers in responding to cholera, boosting communications strategies and developing emergency kits, which include sanitation and water purification materials, to keep outbreaks in check.

[T]o be effective anti-cholera actions must not be merely reactive, health experts say. LSTHM researchers observed in Guinea-Bissau that while most people could recite verbatim hand-washing and other hygiene messages, they apply them consistently only when cholera strikes. Changing such behaviour takes years, not months, said LSHTM’s Ensink.

Source: IRIN, 15 Oct 2009

Preventing spread of infectious diseases is everyone’s responsibility – and everyone’s job

Good hygiene starts within the family, but families need better guidance and advice, says new report.

According to a report published today, we must all share responsibility for preventing the spread of diseases such as swine flu, SARS, avian influenza, diarrhoeal and skin diseases, and even the common cold.

The swine flu scare has prompted some to say that we are over-reacting but it is important  to look at the bigger picture – because the next new pathogens are always just around the corner. The regular emergence of new pathogenic strains, and their unpredictable behaviour, means that sustained investment in effective strategies of mitigation and containment make absolute sense.

But if infections are to be kept in check, there needs to be a fundamental change in our approach to hygiene, with more emphasis being placed on empowering families  to take on this responsibility.

Professor Sally Bloomfield of the London School of Hygiene & Tropical Medicine and one of the report’s authors,  comments: ‘Although antibiotics and vaccines have given us unprecedented ability to prevent and treat killer diseases, hygiene is still fundamental to winning the battle against infectious disease in both developed and developing countries – and that’s a job for all of us. This is not about shifting responsibility, it’s about facing reality’.

The report, published by an expert group for the International Scientific Forum of Home Hygiene, indicates that a significant proportion of global infectious disease could be prevented through improved hygiene practice coupled with the provision of adequate water and sanitation. One of its key conclusions is that, if the burden of these diseases is to be contained in a manner which is economically sustainable, it must be a responsibility which is shared by all of us.

Information around hygiene is still too fragmented and confusing, however. For example, advice on preventing spread of colds and flu is very different from that on preventing diarrhoeal diseases. What is needed, argue the authors, is a less agency-centred approach, and one that is more family-centred, empowering parents to better protect themselves and their families against infection.   Dr Elizabeth A Scott, also a co-author comments: ‘The key to getting people to change their behaviour is to find a way to make hygiene behaviour more appealing and relevant by realigning it with other aspects of healthy living such as diet and exercise. People also need to understand that they can be proactive in protecting themselves and reducing their risk of acquiring an infection in their everyday lives’.

If we can prevent infections through good hygiene, we can also reduce the amount of antibiotics we need to prescribe, according to co-author Professor Martin Exner. Overprescription of antibiotics is the main cause of antibiotic resistance, which is threatening our ability to treat infections effectively when they occur.

In developing countries, the huge burden of hygiene and sanitation-related infectious diseases continue to be the most critical public health threat. Says co-author Professor KJ Nath: ‘Much of the focus in developing countries is on investment in community water supply and sanitation in order to meet the Millennium Development Goals, but if the health benefits are to be realised, programmes of hygiene promotion must be implemented in conjunction with improvements in water and sanitation’.

Last week’s report on the state of the NHS called for greater emphasis on ‘disease prevention strategies’ as a means to reduce pressure on NHS budgets.  Infection prevention will be particularly important for the ever-increasing ageing population, for whom infectious diseases can have much more serious consequences which require hospitalisation.

All of these trends underline the need for greater collective effort in better standards of hygiene. Says Professor Bloomfield: ‘In the current climate where infectious disease agents and our immunity to these agents are constantly changing, we need to return to the “not-so-good old days” when our parents and grandparents knew that protecting themselves and their families against infectious diseases was part of their responsibility and an important part of daily life’.

The full report “The global burden of hygiene-related diseases in relation to the home and community : an IFH expert review” can be downloaded here

Source: IFH Press Release, 17 June 2009

Cambodia: hand washing a low priority in rural areas, ARDA study says

Only one in four rural Cambodians practice appropriate hand washing regardless of access to clean water and hygiene knowledge, according to a recent study presented by the Adventist Development and Relief Agency (ADRA) at the World Federation of Public Health Associations/American Public Health Association (WFPHA/APHA) Annual International Health Breakfast held in San Diego, California.

Dr. Leonard Uisetiawan, provincial projects advisor for the ADRA office in Phnom Penh, Cambodia, who presented the study [said] that less than 26 percent of rural Cambodians use good hand washing techniques regardless of access to clean water and hygiene knowledge. In addition, less than 6 percent of child caretakers properly washed their hands after changing a child’s soiled diaper or after defecation.

This research, funded by Colgate-Palmolive through the American Public Health Association, also highlighted that the practice of hand washing in Cambodian homes is not dependent on the availability of soap, water, buckets, accessibility to hand washing areas, household size, amount of children, mother’s vocation, or educational level.

[…] The Hand Washing Research Project has been conducted over the past year as part of “Phum Mittapheap Koma”, a three-year initiative aimed at improving rural health and reducing morbidity and mortality among more than 22,500 women and 17,400 children in the Kampong Thom province.

View a presentation of the Cambodian study here

See also two other related presentations by Colgate Palmolive Research grant recipients:

R. Courtney Cawthon: Hand Washing Education in Quezalguaque, Nicaragua;

Tova Reichel: Using the Child-to-Child Approach in Promoting Positive Hygiene Behaviors among Orphans and Vulnerable Children (OVC) in Rural Western Kenya 

Source: Satha Sin, Nadia McGill and Hearly Mayr, ARDA, 31 Dec 2008 ; WFPHA Monthly E-newsletter, Nov 2008

Nepal: Toilet use campaign

Butwal: A campaign for children, youth and elderly has been started to change the habit of people who defecate in the open despite having concrete toilet in their homes. The campaigners visit all houses every day, monitor toilet and teach children and elderly people how to use toilet [and to wash hands with soap and water or ash and water after toilet use]. They have made a rule to fine open defecation.

[…] “It took a lot of time and hard work to make the elderly people use toilet who had been defecating in the open from their childhood,” said Krishnabati Verma, president of the campaign.

Source: Kantipur / NGO Forum, 25 Oct 2008

Handwashing behavior in rural Bangladesh

The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) conducted a baseline evaluation for a large intervention project [SHEWA-B: Sanitation, Hygiene Education and Water supply-Bangladesh] that has a primary objective of promoting handwashing with soap or ash at key times–before preparing food, before eating or feeding a child, after defecating and after cleaning an infant who has defecated. In 100 randomly selected communities in 34 districts of Bangladesh, field workers observed the proportion of persons who washed their hands and 2 months later returned to the same communities and interviewed residents about their handwashing behavior. Among the 20,546 key times observed, study subjects washed their hands 11,800 (55%) of the time, though in only 350 episodes (1.7%) did they wash both hands with soap or ash. Efforts to improve handwashing in Bangladesh need to focus on transforming people’s hand rinsing practice into thorough handwashing with soap.

Read more: Health and science bulletin, vol. 6, no. 3, Sep 2008

See also: Health impact: 20 to 50 per cent of children and hard core poor defecate in the open, Bangladesh survey shows, Source Weekly, 12 Jun 2008