1. Hygiene Promotion in emergencies
Orientation package
December 2007

2. Hygiene Improvement Framework
This model is based on the USAID model of Hygiene Improvement – you can adapt this for the emergency situation. It is important to show the links between hardware (provision of facilities) and software (hygiene promotion and enabling environments).
The aim of hygiene improvement is to improve health or ensure that there are no outbreaks of water and sanitation related disease.

3. Exercise 1 (15 minutes total)
In small groups provide examples of what might be included under ‘enabling environment’, ‘hygiene promotion’, and ‘access to hardware’ (10 minutes)
Each group calls out a few examples for each
Clarify and discuss using completed example on next slide

4. This slide provides examples only of different parts of the model, but it is not fixed and the list is not exhaustive. Participants may come up with other examples that can be added. The purpose of the model is to show the necessity and inter-relationship of all the aspects of a WASH intervention and the role that hygiene promotion has to play.
Mention the limitations of the model: e.g. separation of hardware and software may give the impression that they function independently but should be working very closely together; can ORS and ITNs be regarded as hardware? Care must be taken when providing ORS, water treatment agents or ITNs that people know how to use them in the same way that people may need support to get the best out of the provision of latrines.In this way they can be considered as ‘hardware’.

5. Hygiene Promotion
Hygiene promotion is the planned, systematic attempt to enable people to take action to prevent or mitigate water, sanitation, and hygiene related diseases.
It can also provide a practical way to facilitate community participation and accountability in emergencies.
It involves ensuring that optimal use is made of the water, sanitation, and hygiene enabling facilities that are provided.
Key terms should include
Planned
Systematic
Enable
Action
Optimal Use

6. Terminology Hygiene education
The provision of education and/or information to encourage people to maintain good hygiene and prevent hygiene related disease.
It remains a part of Hygiene Promotion and is often most effective when undertaken in a participatory or interactive way.
Health promotion
The process of enabling people to increase control over, and to improve, their health.
The focus is on broader health issues rather than just those associated with water and sanitation.
People are often confused by these different terms - more information can be found in the handout on Terminology and Definitions

7. Why do we need Hygiene Promotion?
The following slides provide a justification for the incorporation of Hygiene Promotion in all water and sanitation interventions in emergencies.

8. Transmission of diarrhoeal disease
A major focus of hygiene promotion is often the prevention of diarrhoeal diseases. However other water and sanitation related diseases may also be targeted e.g. malaria or dengue, either by specific WASH teams or by separate agencies. When trying to address any disease, it is important to coordinate with the agencies providing medical and health care. Coordination within and between agencies (including government) working in different sectors is also important.

9. Why do we need Hygiene Promotion?
The priority focus of Hygiene Promotion in an emergency is the prevention of diarrhoea through:
The safe disposal of excreta
Effective handwashing
Reducing household drinking water contamination
It is important initially to focus the intervention as far as possible. If attempts are made to address too many hygiene issues then the effectiveness of the work will become diluted. However, the focus will depend on the specific context and in some situations it may be more relevant to address food hygiene or solid waste disposal where household drinking water is of good quality and excreta is being safely disposed of. REMEMBER that a major aspect of food hygiene is, in fact, effective handwashing.

10. The graph represents the impact of different components of a water and sanitation programme on the incidence of diarrhoea - showing the importance of handwashing, sanitation, and household water quality. The data usually triggers a lot of controversy as it is difficult to separate out the different elements and all are important e.g. you cannot effectively wash hands without water. The studies also relate to the developmental context rather than to emergencies. However, the research emphasises the contribution that handwashing, sanitation, and household water quality can make to reducing the incidence of diarrhoea.
These three components usually form the major focus of hygiene promotion in emergencies.

11. Why do we need Hygiene Promotion? 1. Optimal use of facilities
Facilities may not be used or may be used in a way that was not intended
Discussions with users can ensure the best possible design of facilities
Systems that ensure the cleanliness and maintenance of facilities need to be set up
If toilets are simply constructed without prior discussion with the users, it is very likely that they won’t be used. For example people may feel that they do not offer enough privacy or that the squat hole is too large and dangerous for children to use. They may prefer to have a pour flush design. Pregnant women may have trouble getting into a latrine that is too narrow. Elderly people may have trouble squatting. If there is no system for cleaning the latrines people will rapidly stop using them.

12. Why do we need Hygiene Promotion. 2
Why do we need Hygiene Promotion? 2. To support participation and accountability
The hygiene promoters will usually have the most contact with affected communities. Their remit is to listen to the communities’ viewpoints. Whilst this should focus on hygiene, very often they will need to be sensitive to other community needs and priorities and respond where possible.
It should be noted that Hygiene Promotion programmes can become disempowering or fail to listen to and respect the views of the affected community if they do not make a conscious effort to include this objective in the way the programme is carried out.
Where hygiene promoters are not able to respond directly, they are in a good position to advocate on behalf of women, men, and children or to request the support of another agency. They can help identify vulnerable groups and support them. They will also be responsible for monitoring community satisfaction with facilities and/or hygiene items/kits and for responding to this where possible.
Photo: IFRC

13. Why do we need Hygiene Promotion. 3
Why do we need Hygiene Promotion? 3. To monitor the acceptability of facilities and impact on health
This is partly related to encouraging participation and greater accountability. Active monitoring should lead to decisions being made to try and improve or change the situation e.g. change the design of the facilities. Regular interaction between the engineers and the hygiene promoters working and listening to community concerns, is required to achieve this. At the very least the links that hygiene promoters create and build with the affected population can ensure better communication with those responsible for the overall response.
Health itself is not measured but the individual or collective actions/practices/behaviours of those affected impact on health and can serve as a substitute. Links with local clinics/health personnel can ensure that a timely response is made to an outbreak of disease or that consistent information is given on the use of ORS or medicines where required.

14. Sphere & Hygiene Promotion Standard 1:
All facilities and resources provided reflect the vulnerabilities, needs, and preferences of the affected population.
Users are involved in the management and maintenance of hygiene facilities where appropriate.
The Sphere project aims to enhance accountability in emergencies and provides a set of standards and indicators for four different sectors including water, sanitation, and hygiene. In addition to this there is a chapter of standards common to all the sectors, that includes standards on participation, assessments, and monitoring. Some of these standards and indicators will be referred to in subsequent slides. More can be found on Sphere at
Hygiene Promotion in Sphere is seen as a core issue in a water and sanitation programme and there is one key standard. Specific aspects of Hygiene Promotion are then included in all of the subsequent water and sanitation standards

15. Team integration Team goals and objectives
Joint work planning and systematic sharing of information
Joint field visits and training where possible
Shared monitoring and reporting systems
Joint interagency meetings
It is vital that engineers and hygiene promoters work together to ensure that the maximum benefit from the intervention is achieved.
Hygiene promoters must inform engineers of community feedback and engineers must be prepared to clarify and use this feedback to inform the design and siting of facilities etc.. Joint community discussions can be arranged and training of water committees should involve the engineers. Even when training community mobilisers, it is helpful if engineers attend some of the sessions to meet and familiarise themselves with the field workers.

16. Hygiene Promotion is not just about message dissemination and behaviour change
Message dissemination is essentially a one-way method of communication and where messages are used they need to be based on what people feel, think, and do. In an emergency even short-term behaviour change can be important in reducing public health risks, and this can happen quite quickly i.e. people taking action. Emphasise actions that are feasible and not just awareness raising or disseminating messages. Messages where used must be based on previous discussion and interaction.

17. Effective Hygiene Promotion emphasises: action and dialogue
Two-way communication is necessary to mobilise and motivate individuals and communities to take action.

18. Exercise 2 (20 minutes total)
In groups of 3, brainstorm some Hygiene Promotion activities (10 minutes)
Discuss in plenary (10 minutes)

19. Components of Hygiene Promotion
This is a model of the components of Hygiene Promotion in emergencies and is also included in the briefing paper. Subsequent slides give examples of the individual components.

20. Hygiene Promotion activities
Use & maintenance of
facilities
Hygiene Promotion activities
Feedback to engineers on design and acceptability of facilities
Establish a voluntary system of cleaning and maintenance, or train latrine attendants
Identify, organise, and train water and sanitation committees
(with engineers) and/or latrine attendants
Specific activities will depend on the context but activities should be geared to achieving the outcome of optimal use of the facilities provided, in order to achieve the aim of the programme which is to prevent outbreaks of water and sanitation disease.
Training is also a key activity of hygiene promoters. They will need to train and supervise/support outreach workers, teachers, or children’s mobilisers as well as committee members and water point or latrine caretakers. Caretakers can also be involved in providing hygiene information to users e.g. encouragement of handwashing with soap.
Other expected outcomes might be:
All water points and toilet blocks have a trained caretaker active during daylight hours
Trained water and sanitation committees are functioning in all zones of the camp
Expected outcome:
The toilets provided are used by men, women, and children in comfort and safety, and are kept clean.

21. Hygiene Promotion activities
Community participation
Hygiene Promotion activities
Consult with affected men, women, and children on design of facilities, hygiene kits, and outreach system
Support community organisations, organisers, and communicators
Carry out a basic gender analysis and disaggregate
assessment data
Identify and respond to vulnerability (e.g. disabled people,
elderly people)
Community participation is discussed in more detail in a subsequent session.
Other expected outcomes referred to in Sphere are:
‘women and men are given the opportunity to comment to the assistance agency…..’
‘assistance programme objectives should reflect the needs, concerns and values of the disaster affected people…’
‘programming is designed to maximise the use of local skills and capacities…’
By tapping into community networks, those with disabilities can be identified and, in conjunction with the engineers or technicians, appropriate solutions can be identified. ‘Hygiene Promotion’ is also the responsibility of the engineers and managers on the programme!
Example expected outcome:
People with disabilities are identified and solutions are found to ensure their improved access to water and sanitation facilities.

22. Hygiene Promotion activities
Selection &
distribution of
hygiene Items
Hygiene Promotion activities
Consult on content and acceptability of items for hygiene kits and advise logistics personnel
Ensure optimal use of hygiene items (e.g. potties, ITNs)
People will not always use the items distributed for the purpose for which they were intended e.g. water filters may stay in their packaging and be kept as assets to sell in times of greater hardship. Soap may not always be used for handwashing at key times etc.
If ORS and/or water treatment agents are being distributed, people need to know how to use them. Mosquito nets and insecticide treated plastic sheeting may also not be used appropriately by those for whom they are intended. Cloth is often distributed instead of actual sanitary towels (allowing women to free up old material to be used as sanitary pads) but this needs to be discussed with women. If disposable pads are used these could block toilets if people are not aware of the importance of disposal systems.
Some agencies have separate systems/teams that carry out distribution. There needs to be co-ordination with them to ensure that those affected are allowed to identify appropriate hygiene items and to ensure that people know how to use the items in the best way possible.
Some agencies may distribute ORS through their health promoters but not all. The promotion of ORS – homemade or otherwise must be done in conjunction with the Ministry of Health or equivalent, and government guidelines and policy on this must be adhered to. Some countries may not yet have introduced the recent changes in the management of diarrhoea (e.g. the use of zinc with ORS) but there will usually be a plan for this and agencies must keep themselves informed.
Nappies/cloth for babies’ excreta and potties for younger children may also be provided in hygiene kits.
Example expected outcome:
Men, women, and children use hygiene items effectively to improve hygiene

23. Hygiene Promotion activities
Individual &
community action
Train outreach system of hygiene promoters to conduct home visits
Organise community dramas and group activities with adults and children
Use available mass media e.g. radio to provide information on hygiene

24. Hygiene Promotion activities
Individual &
community action
Example expected outcome:
75% of (men, women, and children) wash their hands with soap after using the latrine, within 4 months of starting the intervention
Example expected outcome:
Communities are mobilised to dig drainage ditches around their shelters
Households can often become involved in small-scale drainage systems and may contribute labour or be recruited to work on the larger scale drainage systems.
Households can also dig rubbish pits or agree to empty rubbish at specific collection points in the settlement. This can often become a major focus for a sanitation programme in large-scale emergencies
Photo: IFRC
Photo: IRC

25. Hygiene Promotion activities
Communication
with WASH
stakeholders
Hygiene Promotion activities
Collaborate with government ministries and personnel
Train women’s groups/
co-operatives, faith based institutions, government
workers, and national NGOs
A key aspect of the initial assessment for Hygiene Promotion should be the identification of existing capacity, resources, and guidelines, especially in relation to collaboration with government. Duplication of resources or the setting up of parallel systems should be avoided at all costs.
Example expected outcome:
‘Programming is designed to maximise the use of local skills and capacities…’
Photo: IFRC

26. Hygiene Promotion activities
Monitoring
Hygiene Promotion activities
Collect, analyse, and use data on:
Appropriate use of hygiene items
Optimal use of facilities
Community satisfaction with facilities
Monitoring can be done in a variety of ways using participatory methods, observation and short questionnaire surveys. A list of key WASH HP indicators is available.
Example expected outcome:
“Systems are in place to ensure the regular collection of information… to identify whether the indicators for each standard are being met” e.g. in relation to disability (Example from Sphere)
Photo: OXFAM

27. Project Cycle and Hygiene Promotion steps
As with any intervention you need to follow the project cycle. Depending on the level of risk, these stages may need to be condensed or run in parallel. In an acute situation you would do a very rapid assessment and start implementing straightaway while carrying on with the assessment process.
Often you have to develop a baseline with a more systematic collection of data once implementation has started. If a questionnaire survey is feasible try to initiate this within six weeks to two months of onset of intervention. The initial assessment will usually be in the form of qualitative data. For the baseline you need to have collected both qualitative and quantitative data.

28. Hygiene Promotion first steps
Work in close liaison with other members of WASH team
including engineers/technicians/logisticians, and coordinators.
Conduct rapid assessment and identify high risk practices and disease burden
and positive practices and motivation for these.
Explore community organisation and dynamics
including opinion leaders and influential men, women, and children.
Identify channels of communication (traditional and modern):
use a mix of directive and message based (mass media) methods and interactive methods that encourage feedback and discussion.
Set objectives and indicators and collect baseline data
in conjunction with engineers and other team members.
Monitor process and action taken
This slide reduces the many different steps required in carrying out Hygiene Promotion to its essential elements. The key elements are listening and communication to, and with, those affected, other team members, other agencies (including government), and other sectors.

29. Communication approaches
Child to child
NB – A Hygiene Promotion approach usually uses a variety of different methods and tools. A ‘method’, here, refers to a specific activity such as using a pocket chart or carrying out a mapping exercise or using radio or video (see terminology and definitions paper). Clarify this with participants.
The ‘child to child’ method recognises that children can be a force for change. Older children often look after their younger siblings and are therefore key caretakers. Children can also influence other children and their families to engage in practices that will improve their hygiene. While it may not be feasible to introduce a formal child to child programme, child to child methods can be adapted and carried out in schools, clubs, or anywhere in the camp or settlement, and by teachers and/or trained facilitators.
Child protection is an important consideration and an awareness of these issues must be part of the training of children’s facilitators.

30. Communication approaches
PHAST?
Faster PHAST
CHAST
‘Participatory hygiene and sanitation for transformation’ (PHAST) is an approach that makes use of a set of participatory methods and tools used with community groups to motivate their engagement in improved hygiene and sanitation. Trained facilitators take community groups through a sequence of steps by regularly meeting with them over a period of several months.
Faster PHAST was developed by IFRC and others to apply these tools over a shorter period of time in emergency contexts, by reducing the number of steps involved.
Despite this it may not be feasible to meet regularly with the same groups in the acute stage of an emergency. However, the participatory principles and tools that PHAST recommends can still be employed during an emergency.
CHAST is an approach to working with Children based on the PHAST step by step methodology

31. Communication approaches
Social marketing?
Campaigns
Peer education
Other approaches that are common in hygiene promotion in development contexts are social marketing and peer education.
Carrying out social marketing in the acute stage of an emergency is not feasible but it may be possible to use some of the principles, methods, and ideas from social marketing and adapt these to the emergency context.
Social marketing will often adapt the concept of peer education (training people of one peer group to work with others to promote health or hygiene to their own peer group) in its programmes. Social marketing uses a variety of methods and tools as a basis for promotion.
Social marketing uses the principles of marketing to promote something that has social value e.g. mosquito nets, condoms, handwashing with soap. Often makes reference to the four ‘p’s: product, price, position/place (on the market – distribution mechanisms etc.), and promotion.
The focus is on the "consumer" and it involves in-depth research and constant re-evaluation to make the four ‘p’s responsive to the needs of the consumer. This may not be possible in the acute stage of an emergency but the principle of trying to get inside the skin of the consumer is a good one to bear in mind and ongoing assessment/research should help to refine the initial response in an emergency.
Campaigns are also used in social marketing and these can be used effectively in an emergency. They should be short and sharp and focus on the key issues.

32. Communication methods
Mapping
Drama
Games
Home visiting
Interactive methods are time consuming but are often more effective than using the mass media. (NB. Trade off between reach and effectiveness). They are a good way to understand the community perspective and can be used as assessment techniques as well as mobilisation techniques. However, the participatory approach does not always come naturally to those who are not familiar with these methods and outreach workers will often need to be trained to use them and then be well supported.
Pocket chart voting
Discussion groups
Three-pile sorting

33. Communication methods
Radio Programmes
TV/Video
Leaflets
Posters/Notice boards
The above methods usually use one-way communication and are more directive in nature, focusing on the dissemination of messages.
These methods can be made more interactive by forming discussion groups that discuss the material previously presented. Stand alone posters may not be effective because they do not take into account the visual literacy levels of the population (pre-testing can help to address this but may still not be very effective in the short term)
NB Visual Literacy – the ability to ‘read’ pictures is something that has to be learnt as people may not be used to the conventions used in drawing e.g. perspective

34. Hygiene Promotion systems in emergencies
This does not have to be the only system used in Hygiene Promotion but it is the most common. Alternatives are ‘water and sanitation committees’ or ‘community health clubs’. In Sierra Leone UNICEF trained a ‘Blue Flag Volunteer’ to cover ten households. These volunteers provided information about hygiene to their neighbours and were able to make up ORS if there were any cases of diarrhoea in the neighbourhood. In Zimbabwe the concept of ‘health clubs’ has been used.
The numbers of outreach workers depends on the context – how far they have to travel and the urgency of the situation
Structure will depend on context. Alternatives are: Community Health Clubs or Water and Sanitation Committees
Sphere recommends at least 2 outreach workers per 1,000 population and WHO 1:1000

35. Participation and Accountability

36. Participation Ladder Empowerment Partnership Involvement Consultation
It is sometimes useful to think of participation in terms of the participation ladder.
There is always some space for participation even at the height of an emergency but usually this will be at the bottom of the ladder and relate to ensuring the provision of information and consulting as many different groups as possible.
However, different levels of participation may be appropriate at different stages of the emergency. You can go up and down the ladder depending on the situation. For example in a refugee camp that has been in operation for some time, it may be possible for refugees to make decisions about how the programme is run via water and sanitation committees etc. However, if there is suddenly a large-scale outbreak of AWD (Acute Watery Diarrhoea) among those refugees, it may be necessary to take a more top down approach for a while in order to act quickly until the situation is under control.
It is important to avoid getting into a ‘doing and directing rut’
Consultation
Information

37. Disaggregation of data
Sex distribution of cholera cases,
Kiryandongo Refugee Camp, Masindi, IRC
If data is not disaggregated, the differences may be missed. Ask participants why they think there is this difference between male and female cholera cases. The main reason is that women are often primary caregivers and are more at risk of catching cholera from family members they are taking care of.

38. Activities to promote participation
Listen to men and women separately and analyse their different perspectives and needs
Identify those who might be vulnerable (e.g. women, young children, elderly, those with disabilities, or minority or excluded groups) and ensure access to facilities, information, and education
Feed back information to those affected (e.g. from surveys or meetings)
When possible, allow people to set their own objectives for action and to determine the success of the intervention
It is preferable to employ male and female staff to enable men and women to feel comfortable discussing sensitive issues. However, listening skills, empathy, and respect are vital in all staff; a male staff member with such skills may be more successful talking to women than a female staff member who lacks these skills. In some countries and cultures this may be unacceptable.
You may also need to think about different age groups (e.g. youth) and separating older married women from younger, but the urgency of the situation will limit your capacity to seek information from every group initially.
Vulnerability can take many forms and not all women are vulnerable. Caste is a major issue in South Asia. Religion, tribal group, or clan can also be an issue in many regions.

39. Improving accountability
Facilitating participation
Monitoring intervention – including satisfaction and acceptability and impact on health
Link between those affected and other actors
Hygiene promoters can be a key resource for promoting practical accountability if they ensure that they listen to those affected and use that information to inform programme decisions or to advocate for change in other sectors.

40. Exercise 3: 15 minutes
In small groups consider what you can do in this context to ensure:
that women, men, and children participate in the WASH emergency response
that WASH initiatives are accountable to the affected community

41. Practical accountability
Feed back concerns of the affected community and advocate for these to be addressed
Ensure men and women are aware of their rights and entitlements (e.g. with regard to hygiene kits)
Ensure monitoring system is in place and that it is used to inform future activities
Monitor satisfaction and participation
In the previous exercise the participants may have given examples of how to promote accountability. If the group has very little experience of this it may be preferable to show this slide prior to the exercise to kick start the discussion.