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Hygiene and Sanitation Promotion
Effective sanitation and hygiene cannot be “delivered” by an external agency; they are goods and behaviors which
communities and households must want for themselves. While a latrine or public toilet can easily be paid for by
public authorities, these facilities will not constitute effective sanitation unless people want to use
them. Promotion in this Guide refers to the processes by which demand for sanitation hardware and hygiene
behavior change is generated.
Hygiene promotion
Every day, some 6,000 children die from diseases associated with
inadequate sanitation, poor hygiene, and unsafe water; diarrhea alone kills
one child every 20 seconds. However, an effective hygiene promotion
program can reduce the main risky hygiene practices and conditions for
children, women, and men. For example, the simple act of washing hands
with soap at key times such as after going to the toilet can reduce
diarrhoeal incidence by nearly half. In this Guide hygiene promotion is
defined as the processes to promote changes in behavior to reduce the
spread of sanitation-related diseases, e.g. washing hands with soap at
critical times, and safe management of children’s feces.
Sanitation promotion
While hygiene promotion seeks to change behavior concerning personal
hygiene, sanitation promotion is designed to stimulate household demand
for the sanitation hardware necessary to maintain a healthy environment:
latrines, toilets, sewer connections, etc. “Demand” here means more than
just “desire”; it reflects that desire through a “willingness to pay” towards
the cost of the infrastructure. Issues around subsidies are discussed in the
section of the Guide addressing financing sanitation.
Broadly speaking,
hygiene promotion
focuses on changing
personal
behavior. Both are
essential to maximize
the benefits of
investments in water,
sanitation, and
hygiene;
whereas
sanitation promotion
focuses on stimulating
demand for ownership
and use of a physical
good.
In this section ...
Basics of Hygiene
Promotion
Basics of Sanitation
Promotion
Hygiene Promotion
Approaches
Planning and Financing
Hygiene Promotion
School Sanitation and
Hygiene
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Basics of Hygiene Promotion
Hygiene promotion is a planned approach which encourages people to
adopt safe hygiene practices and behaviors
Water pipes, toilets and soap do not, in and of themselves, improve health; it is the way they are put to use that
reduces the risk of disease. Broadly speaking, hygiene can be defined as the set of human behaviors related to
cleanliness and health. In this Guide, hygiene refers specifically to those behaviors related to the safe management
of human excreta, such as handwashing with soap or the safe disposal of children’s feces. Hygiene thus
determines how much impact water and sanitation infrastructure can have upon health, because it reflects not the
construction, but the use, of such facilities.
Hygiene is a very personal subject, and encouraging
changes in hygiene requires skill and care. These
challenges are the subject of hygiene promotion.
Hygiene promotion is a planned approach which
encourages people to adopt safe hygiene practices
and behaviors to prevent diarheal and a number of
other infectious diseases.
Effective hygiene promotion
In the past, hygiene promotion programs often tried
to target a large number of hygiene related
behaviors. For hygiene promotion to be more
effective, however, it should focus on trying to affect
two, or at the most three, key behaviors. Those key
behaviors should be chosen carefully. They should:
z
z
z
reflect the objectives of the project as well as the needs of the project beneficiaries;
maximize the positive impact on public health; and
be amenable to change through well-designed and implemented interventions; challenges from major
social, cultural and economic barriers should be minimized.
Hygiene promotion is all about communicating with the target audience. For communication to be effective, it
needs to:
z
z
z
be inspired by what local people already do;
build on what they already know; and
come from trusted sources.
Hygiene education
Hygiene promotion is a broader concept than hygiene education. Hygiene education is concerned with teaching
people about how diseases spread; for example through the unsafe disposal of excreta or by not washing your
hands with soap after defecation.
Although this type of awareness-raising may be part of a larger hygiene promotion program, it should not be the
sole focus of the program. Both research and field experience show that mere hygiene education rarely results in a
desirable and sustained behavior change; people’s belief systems about health run deep and resist change; in any
event simple technical knowledge is not, by itself a powerful motivator for behavior change. Hence, more needs to
be done than just ‘educating’ people to change or adopt new hygiene practices.
Another false assumption is that health is the overriding concern for people. Research shows that health is seldom
the most effective motivator for adoption of hygienic behaviors. Cleanliness, modernity, self-respect, a sense of
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purity, elimination of bad smells and other factors are frequently cited as more powerful motivators than health
among those who adopt better hygiene and/or sanitation.
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Basics of Sanitation Promotion
There is no point in trying to sell, or even give, a sanitation facility to a
household that does not want it
Sanitation has been part of development projects for many years but with mixed success. Low priority and
inadequate funding can only be part of the failure of many sanitation projects. A more critical problem is probably
poor program design and insufficient site-specific investigation with target populations to determine what kinds of
sanitation facilities they want and are willing and able to maintain.
There is absolutely no point in trying to sell, or even give, a sanitation facility to a household that does not want
it. There is therefore a need to understand both existing consumer demands and requirements for sanitation, and to
stimulate new or latent demand for sanitation. Sanitation services need promotion just as much as hygiene
improvements require promotion, although the “drivers” of demand may be different. Sanitation promotion frequently
focuses on the attractiveness, usefulness and convenience of having and using household sanitation facilities.
Successful approaches will vary in different geographical contexts, and between rural and urban settings. There
are several possible approaches to sanitation promotion; two promising methods, currently being tried in a number
of countries are briefly described below.
TOTAL SANITATION
SANITATION MARKETING
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Total Sanitation
TOTAL SANITATION
SANITATION MARKETING
The Total Sanitation Approach was first developed and tested in Bangladesh with impressive results as 400 villages
completely eliminated open defecation. The approach is now also widely used in India, and is being adapted for use
elsewhere in Asia and Africa.
Total Sanitation Approach aims to achieve universal use of toilets and the elimination of open defecation in
the communities targeted. It differs from earlier sanitation approaches in its focus on the community (rather than
the household) and in its emphasis on collective decision making and local problem solving; this contrasts with
previous more directive programs. The focus on stopping open defecation ensures that every household owns or
shares the use of a toilet and that these toilets are effectively used by all.
The Total Sanitation Approach relies on the
creation of demand for the elimination of open
defecation (and hence for toilets), and is not a top
down approach where toilets are chosen and built
for communities by an external project. The first
step is to raise awareness of the risk of open
defecation and to reinforce a natural sense of
‘disgust’ about this practice.
NGOs
together
with
community-based
organizations and the community at large
participate in a number of exercises to assess the
water and sanitation situation in the community as
well as the location of open defecation sites.
Through
various
participatory
exercises,
discussions and awareness raising activities a
community plan is developed to stop open
defecation, and promote more hygienic individual
behavior.
Village entrepreneurs are encouraged to supply latrine components. The approach stresses promotion of a number
of local options based on affordability and durability. In many cases no hardware subsidy is provided to the
households for the construction of the latrines, although community-wide incentives or rewards are frequently
offered by higher levels of government. Communities may also opt to take loans for construction of toilets or to
establish cross-subsidies within the community. See Selected Publications for more.
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Sanitation Marketing
TOTAL SANITATION
SANITATION MARKETING
Marketing works on the principle of a voluntary "exchange" between consumer and producer where both
gain. Social marketing uses marketing techniques to serve social objectives. Sanitation marketing is about social
marketing, and considers the target population as customers. It borrows private sector experience to develop, place
and promote an appropriate product: in this case the product is a toilet and excreta disposal system, be it sewerage
connection, pit latrine or other mechanism. Critically the facilities must be readily available at an affordable price in
the right place.
The product may be marketed and promoted through various channels including advertising and demonstrations
which aim to make potential consumers aware, informed and interested in purchasing the toilet. This approach is
often summarized by the four P’s of sanitation marketing: Product, Price, Place and Promotion.
Sanitation marketing requires considerable upfront planning and preparation to ensure that product, price and place
respond to local demands and national policy. Early steps in a sanitation marketing program include:
z
Convincing policy-makers of the need to review and standardize the approach to subsidies and redirect
funds towards product development and promotion.
z
Researching current sanitation practices and products, in terms of supply and demand. On the
demand side, this includes establishing people’s attitudes and practices, establishing what they do and don’t
like about the existing situation and what they would most like to change, and what they would be willing to
invest for a better sanitation service. On the supply side it means assessing who provides sanitation
services locally, what types of services they provide, the size of the various market niches, and the potential
to scale up or modify operations to reflect and deliver national policy and/or meet consumer needs better.
z
Researching the motivating factors which will encourage people to invest in a toilet (this is rarely health –
more commonly people speak of privacy, a lack of smells and flies and gaining prestige), along with the
critical target groups and most effective means of communication. Based on this information, an effective
communications campaign must be developed to promote the purchase and use of appropriate sanitation
facilities.
z
Finally developing the right product based on all the above information is critical. A one-size-fits-all
sanitation solution may not exist; different people with different incomes and aspirations in different contexts
will want different types of sanitation facilities. Product development can be carried out directly in the public
sector or through support to and partnerships with private sector suppliers. Product development is
naturally an iterative process, and the piloting of new products before going to scale on communications
campaigns is essential.
The final sanitation marketing strategy will thus be based on the current situation to match supply with a stimulated
demand. Expertise and experience borrowed from the commercial sector can help to ensure promotion of the right
product at the right place and price; their direct engagement on the supply side can contribute realism and
sustainability to the product development and marketing. See Selected Publications for more.
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Hygiene Promotion Approaches
Effective hygiene promotion to achieve impact is one of the most
complex challenges in the water and sanitation sector
Effective hygiene promotion is more difficult, more time consuming, and less assured of tangible or popular success
than construction of drinking water wells, latrines or sewers. On the other hand, better health is more strongly
linked to better hygiene than it is to better hardware provision.
A number of hygiene promotion methods and approaches have been developed and tested over the past decade
with varying degrees of success. None of these methods are fail-safe, and they all need to be adapted to the
context of the country and the objectives of the program. Some of these major hygiene promotion methods are
summarized below.
In this section...
The Participatory
Hygiene and Sanitation
Transformation
(PHAST)
Public-Private
Partnership for
Handwashing (PPPHW)
SANIYA Approach
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The Participatory Hygiene and Sanitation Transformation (PHAST)
PHAST
PPPHW
SANIYA
Some advantages of the PHAST approach
Some disadvantages of the PHAST approach
Analysis of PHAST
The Participatory Hygiene and Sanitation Transformation (PHAST) approach has the objectives of improving
hygiene behaviors to reduce diarrheal disease and encouraging effective community management of water and
sanitation services.
The PHAST approach is based on the principle that the participation of communities in their own projects will
empower the community and improve its decision making about the services it needs and wants to maintain. As
communities gain awareness of their water, sanitation and hygiene situation through participatory activities, they are
empowered to develop and carry out their own plans to improve this situation.
PHAST is based on seven steps using participatory tools, from problem identification and analysis to planning and
selection of appropriate solutions. These solutions may include both construction and management of new physical
facilities as well as adoption of safer individual and collective behavior change.
Some advantages of the PHAST approach:
z
Involving the communities in their project planning and implementation through participatory
techniques can be extremely rewarding for both the community members and community workers (those
who guide the communities through the participatory exercises) and have positive outcomes for the projects.
The main advantages of using participatory tools is that communities gain confidence and responsibility for
their own projects and have a clear say in what they want and do not want.
z
Effective involvement of the community in monitoring and evaluation can ensure that the services put
in place respond to the needs of the community. In addition, such engagement can provide essential direct
feedback to change activities as necessary.
z
Training community workers in participatory techniques. With proper guidance and management, these
community workers can be a real asset to the program and the community. These workers are the direct
link with the communities and can thus reflect the main issues and obstacles back to the program
managers. They can also propose solutions taking the community’s desire and dynamics into account.
Some disadvantages of the PHAST approach:
z
Requires in-depth training of community workers in participatory techniques. On average two weeks are
needed for this training to be completed, to be followed up by regular refresher courses. This has budget
implications.
z
The identification and selection of the community workers are crucial. Indeed, the 2 week training
does not suffice for the trainees to be ready to use the PHAST approach with the community. It is generally
necessary to select experienced community workers to take part in the training. This may lead to several
problems:
{ Experienced community workers may not adapt to participatory approaches easily. They will have
worked extensively with other techniques which stress: ”leadership” and thus may be prone to be
directive and not very participatory. Even with the training, they may still feel compelled to use the
participatory tools in a directive manner. If the program is serious about the participatory approach,
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{
the community workers must be closely monitored, and corrective action taken if the approach is
excessively directive in practice.
Even in-depth training in PHAST does not always suffice. The PHAST approach requires that
community workers have certain character traits: e.g. they must be outgoing, with a good sense of
how the community responds to the participatory tools so that immediate adaptations can be made
during implementation.
z
Requires an intensive management structure. This is feasible in smaller “grass-roots” projects but
becomes problematic if the aim is to “go to scale” at a programmatic or national level.
z
The PHAST tools are relatively time intensive in their use. The approach requires that the beneficiary
communities are available to go through the participatory exercises; this may be seen as a burden if not
properly discussed with the community beforehand.
Analysis of PHAST
PHAST has been implemented in many countries with varying degrees of success. It has not yet been possible to
demonstrate the effectiveness of PHAST with respect to hygiene behavior change or a reduction in diarrheal
disease. Furthermore, there has been criticism from both PHAST implementers and beneficiaries about the
‘childishness’ of the methods used: too simple methods underestimate the target audience. The facilitators have to
be sensitive to each situation and cahning environment. Indeed, if the PHAST approach and the participatory tools
are not adapted to the community where it is being used, the method has a high risk of being abandoned.
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Public-Private Partnership for Handwashing (PPPHW)
PHAST
PPPHW
SANIYA
Some advantages of the PPPHW approach
Some disadvantages of the PPPHW approach
Analysis of PPPHW
The Public-Private Partnership for Handwashing (PPPHW) approach aims to raise awareness, to enhance
political commitment and resource allocation for hygiene, to offer a route to a coordinated national program,
combining them all under one umbrella. PPPHW also uses high-profile and up-to-date methodologies to change the
hygiene behavior which consistently demonstrates the greatest potential impact on overall public health;
handwashing with soap.
To market handwashing successfully, the following four
questions about consumers must be answered:
1. What are the risk practices?
2. Who carries out risk practices?
3. What drivers, habits, and/or environment can
change behavior?
4. How do people communicate?
The answers to these questions provide the key elements of consumer research.
Some advantages of the PPPHW approach
Public-private partnerships (PPPs) provide an effective model for handwashing programs because they combine
the health objectives of the public sector with the marketing expertise of the private sector.
Some disadvantages of the PPPHW approach
Putting together a country team with the commitment, resources, and skills to set up, support, and run a national
handwashing program takes time and effort. Furthermore, public-private partnerships can be slow to build and be
even slower to show results: communication between groups with different traditions, aims, and ways of doing
business are difficult. Personnel changes frequently require that bridge building be repeated
Analysis of PPPHW
Identifying the right partners, building a relationship of trust, and then maintaining their involvement and willingness
to compromise at high levels, are amongst the most challenging, frustrating, and at the same time rewarding tasks
in coordinating PPPHWs to achieve and sustain during the initiative. Peru is an example of a success story.
For the full story, see http://www.globalhandwashing.org and the Handwashing Handbook.
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SANIYA Approach
PHAST
PPPHW
SANIYA
Some advantages of the SANIYA approach
Some disadvantages of the SANIYA approach
Analysis of SANIYA
The Saniya approach was first developed and tested in Burkina Faso (Saniya means cleanliness in the loca
language Dioula). The objective of Saniya is to reduce diarrheal disease in children. It was developed as a response
to research findings from the town of Bobo Dioullaso that the main causes of high diarrhea incidence were the
failure to dispose of children’s faeces effectively and the failure of mothers and care takers to wash their hands with
soap after contact with feces.
The Saniya approach holds that an effective hygiene promotion program must be based on what people know, what
they do and what they want. Hence, a formative research planning approach as shown in the table below is used to
answer these questions.
Table: Saniya Approach
KEY QUESTIONS
Which specific practices are
placing health at risk?
PROCESS INPUTS
What people know, do and Decide on feasible target
want
practice
Who carries out the high-risk
practices?
Who could motivate these
people to adopt safer hygiene
practices?
How can the program
communicate effectively with
these groups?
PROGRAMME DESIGN
Identify target audience
What the hygiene workers
know?
Devise effective motivational
strategies and messages
Establish approriate
communication channels
and design health promotion
materials
This table adapted from ‘ Hygiene promotion in Burkina Faso and Zimbabwe: New approaches to behavior change’ Water and Sanitation
Program, Field Note 7, 2002
The results of the formative research are then used to develop and fine-tune the messages for the hygiene
communication campaign and to promote them using the appropriate communication channels; in this case radio,
theater groups, health staff and teacher training in hygiene promotion and face-to-face domestic visits.
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Some important lessons from the formative research were that the aesthetic and social incentives for hygiene
amongst the target audience (in this case, mothers with small children) were more powerful than those stressing the
need to avoid diarrhea. Hence, messages were built around these ideas.
Some advantages of the SANIYA approach
z
The Saniya approach focuses on promoting a small number of safe hygiene practices. Safe disposal
of children’s excreta and washing hands with soap after contact with fecal matter. This focus reduces the
number of messages to be promoted which will increase the likelihood of beneficiaries picking up the
message and changing behavior, in comparison with attempting to promote a multitude of messages around
water and sanitation which often dilutes the impact.
z
The formative research is flexible and can be easily adapted to different research questions. It provides
solutions from interaction with the community while being relatively time efficient.
z
The communication campaign is based on information provided by the beneficiaries, and the messages
developed reflect their priorities and rationale. This participatory approach targets a specific focus group/s.
Although this approach has only been tested in one city, its principles can be applied to work at a larger scale. Most
of the mass media activities such as radio and health staff and teacher training are easily taken to scale; other
activities like theatre groups and domestic visits will depend on funding and professional staff.
Some disadvantages of the SANIYA approach
z
The formative research requires highly trained and experienced field researchers who can facilitate
delicate discussions on what motivates people’s behavior. It may be difficult to find such researchers, and
additional training will be needed to improve certain research skills.
z
The approach relies on a mix of different types of promotion from mass media like radio to house to
house visits. Monitoring these activities becomes an important part of the program which needs adequate
resources.
Analysis of SANIYA
The Saniya approach has only been implemented in one country so it is difficult to assess its larger impact.
However the lessons from this approach have been the basis for the approach in the Public-Private Partnership for
Handwashing (PPPHW). The PPPHW has learnt from the media mix used in the Saniya approach and has taken it
a step further.
A study on the cost effectiveness of the SANIYA approach used in Burkina Faso has been carried out and results
from this study were the following:
1.
2.
The percentage of carers who practiced hand washing with soap after cleaning a baby’s bottom rose from
13 to 31%; hand washing with soap after latrine use increased from 1 to 17% and safe disposal of children’s
faeces from 80 to 84%. The conclusion was that 18.5% of mothers had effectively changed their hygiene
practices.
The cost of the intervention was US$ 0.65 per head, and an estimated 8,638 cases of diarrhoea, 864 outpatient consultations, 324 hospital referrals and105 deaths were averted by the program.
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Planning and Financing Hygiene Promotion
This section gives a short overview of the key issues in the planning and financing of a hygiene promotion program.
This material has been adapted from information outlined in the documents Sanitation and Hygiene Promotion:
Programming Guidance, A Manual on Hygiene Promotion and The Handwashing Handbook. These documents
should be consulted for further detailed information on the planning and financing processes of a hygiene promotion
program. See Selected Publications for links to these manuals.
In the following sections...
Identify the key objective of the hygiene
promotion program
Finding out what’s going on in hygiene
Building political will - linking hygiene programs to
international movements
Presenting the health costs of poor hygiene vs.
the cost of a hygiene promotion program
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Identify the Key Objective
IDENTIFY
FIND OUT
POLITICAL WILL
PRESENT
COSTS
Identify the Key Objective of the Hygiene Promotion Program
Many water and sanitation programs appear to have a hygiene promotion component just for the sake of having
one; hygiene promotion programs may have a number of vague objectives leading to the development and
promotion of numerous hygiene messages; this promises little likelihood of changing behavior. The first step for an
effective hygiene promotion program is to identify the key objective. A situation analysis can be used
1.
2.
to understand which hygiene behavior currently constitutes the biggest health risk for the target population
and
to establish the extent to which the project can address this behavior.
The major risk may, for example, be unsafe disposal of infant feces or lack of handwashing with soap after using
the toilet and before eating. In each case, the program will need to target a different behavior.
Focus on a few key behaviors is important; increasing the number of targeted behaviors will weaken the impact
of the messages. It is recommended that no more than 2 -3 key behaviors are targeted in a hygiene promotion
program.
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Finding Out
IDENTIFY
FIND OUT
POLITICAL WILL
PRESENT
COSTS
Finding out What’s Going on in Hygiene
Formative research, baseline studies, and monitoring and evaluation
One of the main problems in assessing the health impact of previous hygiene promotion programs has been the
omission of baseline studies. This has meant that it has been extremely difficult to measure and show impact and
this makes it harder for Ministries of Finance and Donors to justify substantial repeat investments in this sub-sector
Today efforts are being made to carry out rigorous baseline studies.
Measuring changes in health status is very challenging.
Seasonal and inter-temporal variations in risk factors
beyond the control of the project can distort outcomes,
while attribution of changes to specific health
promotion activities is extremely difficult. For this
reason there is an increasing reliance on measuring
the adoption of the targeted behavior (handwashing at
key times) rather than an impact on the health (such as
a reduction in diarrheal disease).
Information on how to carry out a baseline study and
monitoring and evaluation can be found in all three
documents referenced for this section in Selected
Publications.
These are inherently linked into selection of indicators
which is yet another challenge.
Consumer research as a sub-set of formative research
Once the key unsafe hygiene behavior has been identified, the development of the hygiene promotion program can
begin. In addition to identifying the key hygiene behaviors, research is also needed to understand why people do
what they do. For example, if people do not wash their hands with soap after using the toilet there may be one or
many reasons including:
z
z
z
z
lack of understanding of the link between the fecal-oral route and diarrhea or the importance of soap;
lack of soap at the household level;
a religious or cultural belief linked to the use of soap; or
simply that handwashing with soap after using the toilet was never a habit engrained at childhood.
An understanding of what drives the current practice enables the program to address the right obstacles. It is also
important to understand what could motivate people to adopt a specific practice. Research has shown that telling
people to adopt a new behavior for health reasons, such as avoiding the risk of diarrhea, is rarely an effective
motivating message. The driver for adopting a new practice may be unrelated to the objective that the hygiene
program intends to achieve.These are the kind of issues that the baseline should be able to capture: have people
even heard about the messages promoting hand washing?
For example, research amongst women in Senegal showed that the driver to adopt the practice of handwashing with
soap after the toilet and before eating was to be seen as pretty; having clean hands is seen as a way to be
seductive which also gives a sense of pride and reveals a certain status in society. This does not have any direct
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relations with the avoidance of diarrhea which may the hygiene programs primary objective, nevertheless,
messages used in the program will be developed and refined using this information.
More information on this type of consumer research can be found in The Handwashing Handbook.
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Building Political Will
IDENTIFY
FIND OUT
POLITICAL WILL
PRESENT
COSTS
Building Political will - Linking Hygiene Programs to International Movements
Few countries have developed specific strategies on hygiene promotion although there are some countries who are
starting to develop such strategies. Because hygiene promotion requires a relatively long commitment in terms of
time, it is important to build understanding and political commitment at the highest level.
To achieve this it may be necessary to hold several meetings/workshops to demonstrate how the hygiene
promotion program may fit within the Government’s own sector development plan. If the country has committed
itself to achieving the Millennium Development Goals (MDG’s).
It may be worthwhile pointing out how a hygiene promotion program can contribute to achieving the objectives set
out in the MDG’s (specifically goal number 4: reduce by two thirds the mortality rate among children under
5). Poverty Reduction Strategies may also be a useful framework within which to promote effective hygiene
promotion.
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Presenting Costs
IDENTIFY
FIND OUT
POLITICAL WILL
PRESENT
COSTS
Presenting the Health Costs of Poor Hygiene vs. the Cost of a Hygiene
Promotion Program
In the past two decades, hygiene promotion programs, if present in larger water and sanitation programs, have
generally been underfinanced. The bulk of project funds are generally destined for water related infrastructure and
to a lesser extent sanitation services and infrastructure. The relatively small funds allocated for hygiene promotion
programs has often meant that these programs could not achieve a noticeable impact on behavior.
Recently, through awareness raising and advocacy activities as well as studies on the impact of hygiene promotion
programs; the international community is increasingly interested in allocating more funds to hygiene promotion
programs. Nevertheless, governments in developing countries may not yet be convinced to spend sizeable budgets
on non-infrastructure related activities. It may therefore be useful to present the cost of poor hygiene: the cost is
both monetary due to the purchase of medication, trips to the doctor, etc., as well as human in terms of number of
work days lost or even death.
It may be worthwhile carrying out a small study on actual health costs incurred by the country due to poor hygiene
and demonstrate how these costs can be reduced through preventive measures like access to water and sanitation
coupled with a targeted hygiene promotion program, demonstrating the cost-effectiveness of such a program.
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School Sanitation and Hygiene
Schools can provide an arena where sanitation can be shown at its best
Schools provide excellent opportunities to support sanitation and hygiene promotion programs. The curriculum
naturally offers opportunities to teach about dirt and disease and what can practically be done to improve health
through better sanitation and hygiene. Construction and use of appropriate child friendly sanitary facilities
(handwashing stations, soap and toilets) can be especially effective in reducing the incidence of diarrhea.
Schools may be better locations in which to
enforce certain behaviors in children than the
home. Schools can also provide an arena
where sanitation can be shown at its best, and
certain positive hygienic behaviors (hand
washing with soap before eating and after
going to the toilet) can become an engrained
habit at a young age.
Nevertheless, hygiene promotion in school
cannot rely solely on teaching and enforcing
certain habits. Research has shown that
children will more willingly change behavior if
they are having fun and if they are following
their peers. Imitation is one of the most
successful forms of learning; hence young
children will look to their older brothers and
sisters or to older school friends to adopt new
behaviors and life skills.
When developing and implementing school sanitation and hygiene programs several key issues need to be kept in
mind:
1) School sanitation facilities: The main users of the facilities are children and designs need to be appropriate.
This is particularly critical for young children around the age of 4 to 5 who are just starting to use the toilet and will
be put off if toilets are too large, dirty or dark.
2) Getting the message right: Schools provide an arena within which to influence children’s behavior. Direct
hygiene education may have limited effect in triggering behavior change; investigations focused on children’s
behaviors, attitudes and interests are needed to develop the right hygiene promotion strategy.
3) Coordination: The Ministry of Education sets educational policy and regulates schools, while water and
sanitation may be the responsibility of a different ministry. It is important to facilitate collaboration between these
ministries, so that resources can be effectively directed at sound and consistent approaches.
4) Linking home with school: Schools are part of the larger community and must be supported by its members. A
school water, sanitation and hygiene program will only be effective if it is reinforced and supported within the
community, and the homes of the students. Hence, a school sanitation and hygiene program needs to be
embedded within the context of a larger community water, sanitation and hygiene program if it is to reach its full
potential.
Click here for more on school sanitation and hygiene.
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Gender, Hygiene and Sanitation
Effective sanitation and hygiene promotion pays attention to gender differences and the effects of such differences
early on in the process to ensure that different groups are treated equitably. No one should be excluded from
hygiene and sanitation services on the basis of their sex, age, disability, socioeconomic, or cultural/ethnic group.
In this section...
Why bother? Advantages of accounting for gender
What is it? Gender in promotion
How to do it? Mainstreaming gender into sanitation and hygiene
action
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Why bother? Advantages of accounting for gender
Why bother?
What is it?
How to do it?
More sanitation and hygiene projects/programs
Greater impact on health
More efficient projects/programs
Enhanced productivity and income
More sanitation and hygiene projects/programs: In many places, women traditionally manage domestic and
community hygiene and the disposal of waste water and solid waste. They are therefore usually more motivated to
improve local conditions and practices than men. Giving women a greater voice in technology choices and the
menu of management and financing options can help to motivate and support more projects and programs.
Experience gained through project participation can also help empower women, especially the most marginalized
(e.g., through improvements in literacy/ numeracy or technical skills; and increased local standing). Men can also be
helped to understand the benefits of such improvements in relation to their own roles and responsibilities.
Greater impact on health: The adoption of good latrine use, handwashing and other hygiene practices varies by
sex, age, class and other characteristics. Messages should be targeted to different user groups in order to achieve
a critical mass of good practice adoption.
More efficient projects/programs: There are
indications that a participatory and gender-sensitive
approach reduces costs of installing sanitation facilities
and providing sanitation services.
Enhanced productivity and income: In some
programs, women have been trained and employed as
latrine masons, health educators and community
mobilizers, both alone and with men. This has resulted in
income gains for women with earnings under their
control, although there have been cases where women
were paid less than men for the same work, or expected
to work as volunteers. For more on sanitation and
livelihoods, see Further Resources.
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What is it? Gender in Promotion
Why bother?
What is it?
How to do it?
Design of promtional messages
Social intermediation during implementation
Social marketing
Management capacity building
Gender affects not only women’s and men’s roles in water and sanitation, but also how they respond to various
promotional efforts. Gender-sensitive formative research should be done before planning a sanitation and hygiene
project/program. Such research can establish the conditions and practices of the different groups and their relative
health risks, what each group considers important changes or reasons for adoption of sanitation, the approaches
that can motivate/keep them from changing these, and the most appropriate communication channels for different
messages to different target groups.
Overall program design should consider the full range of “special” groups: female and male headed households, the
elderly, the disabled. Their position may affect their capacity to collect materials, buy latrines/latrine parts, dig pits,
build outhouses, use toilets, etc
Examples from various stages and elements of promotion are included below.
Design of promtional messages: Messages
should be adjusted to different interests and
conditions of men and women. Motivating messages
to men may be status and responsibility for women’s
and girls’ privacy and safety; hygiene promotion for
men may address their responsibilities to contribute
financially, to do traditionally-male construction tasks
when building toilets through self-help, to use toilets
hygienically and clean them after use, and to
educate children (especially boys) on good
sanitation and hygiene practices.
Explicit inclusion of such messages for men is
needed and cannot be left to diffuse from promotion
aimed at young mothers or women alone; existing
gender norms may simply not allow women and
adolescent girls to raise these issues with men,
whereas the hygiene promotion program should
seek to find a way to identify and address these
questions credibly and effectively.
Men and the poor may be more interested in costs and possible cost-reductions; women may be more interested in
design and usability by children, and in issues of privacy and convenience.
Social intermediation during implementation: Women and men may differ strongly in preferences as to when it
is convenient or possible to attend meetings. Even when convenient, women may not be welcome, may find it hard
to attend because of their poor clothing, may not speak up in front of men or influential women, the promoted
hygiene practices do not reflect their realities, etc. Separate meetings with poor women and men may improve their
participation.
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Social marketing: Segregate target groups by gender (not only males and females, but also age, class, religion,
etc.) before doing research. Assess what facilities/products/services each group wants, motivating/demotivating
factors, perceived vs. actual costs, gendered access to materials, skills, information
Management capacity building: In management capacity building, if the program’s aim is to build local capacities
for planning and implementing sanitation and hygiene projects/programs, the focus on community organization and
capacity building will be greater. Gender balanced institutions (Link) and training then become central. When
promoting total sanitation, it is important to ensure that a representative mix of women and men take part in
identifying the risks and plan, implement and monitor the changes.
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How to do it? Mainstreaming gender into sanitation and hygiene action
Why bother?
What is it?
How to do it?
Gender cannot be made the exclusive responsibility of a social specialist or team. Project management and staff
need to know and agree on the basic approach to gender in the program and work with women and men in a
gender-equitable manner. It is important to include this in capacity building, job descriptions and performance
assessments.
Mainstreaming gender in hygiene and sanitation will be most effective when mutually-reinforcing efforts are made at
various levels. One of the defining characteristics of sanitation and hygiene as a field is the need to address it on a
wide range of levels, from individual households to national government. These levels and their characteristics are
described elsewhere in this guide (link.)
Gender, like poverty, is an issue that will have to be effectively addressed at EACH level, and not just at the
household or community level. Mainstreaming at the different levels involves:
z
z
z
z
z
z
z
National government
Regional/ local government
Urban government
Civil Society Organisations/NGOs/CBOs
Small Scale Private Providers
Communities
Intra-household
See Further Resources for recommended sanitation and gender related publications, and such World Bank
site Gender and Development for more on gender.
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