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Chapter 9. Promoting hygiene

The goal of hygiene promotion is to help people to understand and develop good hygiene practices, so as to prevent disease and promote positive attitudes towards cleanliness. Several community development activities can be used to achieve this goal, including education and learning programmes, encouraging community management of environmental health facilities, and social mobilization and organization. Hygiene promotion is not simply a matter of providing information. It is more a dialogue with communities about hygiene and related health problems, to encourage improved hygiene practices. Some key steps for establishing a hygiene promotion project, possibly with support from an outside agency, are listed in the text box below.

Establishing a hygiene promotion project

Evaluate whether current hygiene practices are good/safe.

Plan which good hygiene practices to promote.

Implement a health promotion programme that meets community needs and is understandable by everyone.

Monitor and evaluate the programme to see whether it is meeting targets.

9.1 Assessing hygiene practices

To assess whether good hygiene is practised by your community, some of the methods discussed in section 2.2 can be used. It is particularly important to identify behaviours that spread pathogens. The following are the riskiest behaviours:

The unsafe disposal of faeces.
Not washing hands with soap after defecating.
The unsafe collection and storage of water.

Key questions for assessing hygiene

What "risky" practices are widespread in the community?
How many people employ risky practices and who are they?
Which risky practices can be altered?
What motivates those who currently use "safe" practices?
Who influences them?
What communication channels are available?
Which communication channels are trusted for hygiene messages?

9.2 Planning hygiene promotion projects

The entire community should be involved in a hygiene promotion project, but this is likely to mean that different groups within the community will have different perceptions and priorities. Women's priorities are particularly important, since women usually ensure that good hygiene is practised in the home. It is crucial to take these different priorities into account and make realistic plans. By consulting all community members, it is possible to identify priorities and achieve solutions more relevant to the whole community.

When identifying community members to carry out hygiene education, it is important to consider the amount of time they will spend on promotional activities and how they will be compensated. The duties and skills required by prospective promoters should also be clearly identified. Existing health staff and teachers may be appropriate as hygiene education providers, but they may not have the time to commit to additional activities or have the skills to carry out activities on sensitive subjects. Other community members may perform hygiene education activities well, but may require training. In such cases, local government bodies and other agencies should be contacted to provide the necessary training and support. Usually, the most effective skills in a promoter are an ability to communicate well with the target group and an understanding of constraints that cause people not to adopt safe practices. People who cannot read or write should not be excluded as promoters if these skills are not required, since that may exclude older women who are respected in the community and have plenty of life experience.

There is no hard-and-fast rule for the ratio of hygiene promoters to community members, but it is generally considered that one community promoter can adequately cover about 1000 community members, provided that it is easy to move between households. Community promoters can be supervised by an outside agency or by local government officials, but the community itself should also be involved to ensure that the programme is effective and responsive to local needs.

9.3 Implementing hygiene promotion projects

Flexibility is essential when implementing a hygiene promotion project. Different community members may need different information and support, and the project as a whole may need to change as it develops.

9.3.1 Building community capacity

To promote hygiene within a community it is not enough simply to provide messages about hygiene; the capacity of the community to analyse situations and initiate changes must also be improved. In this sense, hygiene promotion is comparable to community development activities. Building community capacity may involve:

Operating and maintaining water and sanitation facilities.
Organizing and supporting community groups and committees.
Helping communities to analyse their current hygiene and sanitation.
Negotiating agreements and settlements between development partners.
Encouraging the private sector to develop water, sanitation and hygiene products.

9.3.2 Organizing groups and committees

Groups and committees, such as water and sanitation user groups, may be required to perform hygiene-related tasks, and it may be difficult to involve all members of the community in these groups. Women, for example, may not be able to serve on water and sanitation committees, yet fulfilling their needs is of paramount importance to the work of the committees. In some cases, hygiene promotion staff may be able to encourage the representation of women on committees, but it may be more appropriate to have separate committees for women. When these are established, however, there must be a link to the overall community committee responsible for managing the water and sanitation facilities, so that women's opinions influence management. The women may require special training to develop their confidence and communication skills and to effectively represent women's interests on committees.

9.3.3 Situation analysis

Before a project with a community is started, information about the current hygiene situation should be collected and analysed. This will help to guide project activities and provide a baseline against which changes can be measured. The information collected from a project will also form the basis of other hygiene promotion activities. Situation analysis should not be undertaken by hygiene promotion staff alone, but should involve the entire community, both during the project and afterwards. Hygiene promotion staff can share findings with the community, and help community members to analyse information and identify solutions to problems.

9.3.4 Communication and education

Communication and education activities include selecting appropriate hygiene messages; identifying the target groups for those messages; identifying effective communication methods; preparing communication materials; and communicating the messages. Selecting the appropriate hygiene messages and identifying target audiences require an analysis of information collected from the community. Mothers are often designated as the primary target audience, since they are usually the main caregivers for young children and are most influential in a family setting. While targeting mothers may be useful for influencing change at household level, there is also a need to involve the immediate family and other people who influence women's behaviour.

Accessing target audiences

Who are the members of each target group?
Where are they?
How many of them are there?
What languages do they speak?
Who listens to the radio or watches television regularly?
What proportion can read?
Do they read newspapers?
To which organizations and groups do they belong?
Which channels of communication do they like and trust?

Hygiene education messages can be communicated in different ways, including posters, drama and storytelling, mass media messages, group discussions (Figure 9.1) and home visits. Some methods, such as the use of mass media and posters, communicate messages to large numbers of people. Other approaches emphasize the need to work with small groups, through meetings and household visits. No single method is always effective, however. Most health education works best when interventions are made at different levels and use a mixture of awareness-raising tools, and when they focus on individual activities, such as "child-to-child" programmes or home visits by health educators. Getting households and community members involved in learning about hygiene is often crucial for improving hygiene practices and reducing the risks to health. The messages should be understandable by the target audience. This can be accomplished by first testing educational materials on small pilot groups. More information on hygiene communication and education can be obtained from the agencies and materials listed in Annexes 1 and 2.

Figure 9.1 Health education group

9.4 Monitoring and evaluating hygiene projects

Regular review of hygiene education projects by community members ensures that issues important to the community are covered. Reviews can evaluate whether community members are uncertain or confused about hygiene messages and whether they need further hygiene information. The results of reviews also provide feedback to hygiene educators for improving the programmes. Community members should decide on the frequency with which hygiene education activities are evaluated. Meetings could be held every 1-2 weeks, with assessment based on agreed goals set at each meeting, or less frequently (every 3-6 months) with more lengthy discussions at each meeting. When outside donors have provided funds, they may have their own requirements for monitoring and evaluating the information collected, so it is important that the community members are clear about how such evaluations will be performed and what role the community will play.

Evaluation activities

Try to decide what information is needed. This may require reaching a consensus with all concerned individuals and organizations, a process that may involve lengthy negotiations.

Identify who will carry out the investigations. This, too, can be a lengthy process and depends on the availability and willingness of individuals to help.

Select tools for collecting information. (Who has the information, what form is it in and who will collect it?)

Organize logistic arrangements. Try to make sure that everyone involved in the project is contacted and provided with necessary information in a timely manner. The staff or community members undertaking the evaluation may need guidance on how they should collect information and how they should respond to evaluation issues.

Review findings with investigators. This may need to be coordinated by a committee of representatives from different stakeholder groups.

Provide feedback to all stakeholders about investigators' findings. Different reports will probably be needed for different stakeholders.

9.4.1 Deciding what information is needed

Developing a framework of questions is the first step in monitoring and evaluating a hygiene education programme, and the framework should include a measurement of what has happened and how it has happened. Some of the most common questions to consider are:

Appropriateness. Are project activities the right ones? Do they provide solutions to the most important problems?

Effectiveness. How well are the different activities carried out?

Costs. What does the project cost? What contributions come from the community and are they acceptable?

Participation. Who attends project activity meetings? Are all groups represented in planning, implementing and evaluating the activities?

Sustainability. Can activities be sustained on a continuing basis? If external agencies provide funds, can the community sustain activities after funding has ceased?

Unintended outcomes. Are there outcomes (positive or negative) that were not intended?

9.4.2 Selecting project investigators

The community should be actively involved in any assessment, including the collection and review of information, and should identify individuals within the community to carry out the assessment. Individuals from external support agencies may also assist in the evaluation, which could bring new perspectives to the project and facilitate the collection and review of information. Selecting community members to undertake the assessment requires careful planning; to ensure that assessment results are reliable it is usually best to involve a mix of community members. This mix can include community members involved in the health education project, as well as those who are not actively involved but who have a good understanding of project goals.

9.4.3 Selecting tools for collecting information

The type of monitoring and evaluation tools chosen will depend on the type of information to be collected. This section describes some of the tools available.

Assessment tools

Assessment tools can be used at various points during the project to determine whether interventions are improving community hygiene. Focus group discussions, for example, can be useful for revealing community views and for solving problems that arise during discussions. For more quantitative assessments, questionnaires can be used to record activities and behaviours. The assessment tools should be carefully selected so that the collected information is appropriate to the purposes of the evaluation.

Self-monitoring forms

By using self-monitoring forms, households can monitor their own hygiene practices, or can monitor the incidence of an illness over time. The forms can then be collected and discussed with householders, either individually or as part of a group discussion. Health educators can also monitor their own activities using self-monitoring forms and they should meet regularly to discuss problems and successes. Self-monitoring forms should be easily understandable by users and by individuals who collect and analyse the information.

Trainers' assessment forms

Training sessions should be regularly assessed to maintain their quality. Again, the trainers' assessment forms should be easily understandable by everyone who collects and analyses the information. One way of assessing participants' attitudes towards a training course is to ask them to write down on a flip-chart one positive thing and one negative thing about the course. For those unable to write, a series of pictures representing feelings could be provided and the participants asked to mark those that best represent their own feelings about the training course.

9.4.4 Reviewing project findings

A review committee can be set up to manage the progress of the project and to discuss the implications of its findings; a hygiene committee, for example, could act as the reviewers. From the outset, committee members should be aware of the amount of time that the committee work will entail and understand the purpose of the evaluations. If the evaluation is important mainly to a donor or funding organization, the information collected may need to be representative of the community as a whole and its relevance for improving community hygiene clearly stated against the project goals. However, it may also be important for the evaluation to be used as a means of discussing the direction of the programme and of identifying how the effectiveness could be improved. If the evaluation is geared more towards the community, it can be used to generate further debate about the importance of the hygiene promotion programme and how it can be enhanced by the community itself.

9.4.5 Feedback and dissemination of findings

Information gathered during monitoring and evaluation activities should be shared with the wider community and other interested parties. This is best accomplished by holding group discussions with different sections of the community. Feedback can also be accomplished by posting notices at meeting places, or by presenting the information in the form of a drama. Written information should be summarized in no more than a couple of pages and illustrated with graphs, figures, pictograms and pictures. If information is shared with the community and other concerned people, discussions about progress can lead to new project targets or even to different types of projects.