Hygiene and Sanitation: What are you going to do about

it? And where do you start?

Janet S. Ausel, PE

WASH Advisor

With many thanks to Pamela Crane-Hoover of Lifewater and Lael Kucera of Living

Water International for their contributions.

The Motivation

In 2012, over 1 Billion people practiced open defecation

(14% of the world population or 1 in 7 people)

Do you think they wash their hands?

Why Hygiene and Sanitation Promotion

• Donor driven programming leans toward “clean water” projects

• 11% of the world lacks improved water sources • But 35% lack improved sanitation and 14% have no

sanitation facilities at all • 1.7 million children die every year from diarrhea and

acute respiratory infections who are under five. These figures could be cut dramatically if hand washing with soap were widely practiced

• Statistics vary on efficacy of hygiene programming but bottom line is clean water alone has only a fraction of the impact compared to making headway in sanitation and hygiene.

The F-diagram

http://www.water1st.org/millions-of-children-die-each-year/

Selection of Methodologies

• It is now understood that ‘educating’ people about health benefits is, in many cases, not sufficient to change people’s behavior.

• What behaviors are you trying to change?

– Hand washing

– Sanitation

– Soap use, etc.

• How do you change peoples behavior?

– Law (threat of punishment)

– Motivations/Barriers

– Cultural Norms

Factors Influencing Selection

Effective H&S Programming

Effective Training

& Communi

cation Social-

Cultural Factors

Rural vs. Urban

Environ-ment

Economic

Status

Budget and

Staffing

Legal Frame-work

Govern-ment

Support

External Factors Internal Factors

Programming Frameworks

Relationship of Types of Programming

Sanitation Promotion

Participatory Planning Tools

Hygiene Promotion

PHAST: Participatory Hygiene and Sanitation Transformation

History:

Began in 1993, started by Water and Sanitation Program, World Bank and WHO

http://www.who.int/water_sanitation_health/hygiene/envsan/phastep/en/

PHAST: Overview

• Goal: Hygiene behavior change

• Method: Communities gain awareness of their current WASH status using participatory activities

• Develop and carry out their own solutions

PHAST: Methodology

PHAST: Strengths/Weaknesses

Strengths

• Rewarding for the communities

• Communities gain confidence and responsibility for their own projects

• Pictures and activities facilitate inclusion of illiterate community members

• Has been used since 1993 so many resources have been developed and are available open-source

Weaknesses

• Requires in-depth training of facilitators

• Facilitators need to be winsome

• Relatively time intensive for the communities

PHAST: A Word from the Field

Name: Vũ Hồng Hà

Organization: Samaritan’s Purse

Country: Vietnam

Method: PHAST

CLTS: Community Led Total Sanitation

History:

Developed by Dr. Kamal Kar in Bangladesh, 1999

http://www.communityledtotalsanitation.org

/resource/handbook-community-led-total-

sanitation

CLTS: Overview

Communities analyse and improve their own sanitation status through raising awareness of the harm caused by Open Defecation (“OD”) through virtually

“eating faeces”. Single objective is for communities to become Open Defecation Free (“ODF”)

Focuses on igniting a change in sanitation behaviour rather than

constructing toilets.

Encourages local innovation, and stimulates local / natural

leadership

Not dependent on external services, or on hardware

subsidies

No central latrine design is stipulated. Use of local materials is

greatly encouraged. Embraces concept of “sanitation ladder”.

CLTS: Methodology

Triggering

• Transect walk

• Interactive demonstrations

• People feel disgust/shame

• Leading to a desire to change

CLTS: Strengths/Weaknesses

Strengths • Results in ODF communities • Community members take

ownership and build their own hardware without assistance

• No barrier to sustained use of latrines (not dependent on outside donor)

• Motivates natural leaders to rise up

• Methodology easily reproduced (by natural leaders in the community)

Weaknesses • Requires in-depth training of

facilitators

• Facilitators need to be winsome

• Doesn’t work well where there have been subsidies in the past, in urban centers

• Can be challenging where high water table or unstable soils

• How do you get people to move up the sanitation ladder?

• Unknown if it sustainable over longer periods of time.

CLTS: A Word from the Field

Name: Peter Elim

Organization: Tearfund

Country: DRC

Method: CLTS

Key Points/Lessons Learned

• Work where other people aren’t working since others have subsidies

• Modify the method: In DRC not a pure form of CLTS given the government structure

• Shaming: Government fighting the shame aspect

CHCs: Community Health Clubs

http://www.africaahead.org

History:

Developed by Africa AHEAD in 1994

CHC: Overview

• Goal: Hygiene behavior change

• Promotes a “culture of health”

• Weekly meetings open to entire community

• 23 lessons with homework

• Membership cards and graduation ceremonies

CHC: Methodology

Stage 1: Health Promotion: ~One year for Stage 1 & 2

• Community Mobilization and CHC Formation, Base Line Survey, Health Promotion Sessions, HIV/AIDS Prevention, Home Hygiene improvements

Stage 2: Sanitation & Water

• Encourages self supply of water points and income generation from water points, CHC decide everyone must have sanitation, rubbish disposal

Stage 3: Skills training & Income generation projects

Stage 4: Civic Responsibility

• Supportive social networks for the vulnerable, counseling/coping mechanisms, support for HIV/AIDs or terminally ill

CHC: Strengths/Weaknesses

Strengths

• Members of a CHC have increased learning, raise social status, opportunities for income generating activities

• Does not require literacy

• Effective at various points on the hygiene/sanitation ladder

Weaknesses

• Men not always active participants

• Lengthy period of implementation

• If community members are paid for implementation, not necessarily sustainable

CHCs: A Word from the Field

Name: Lydie Pierre

Organization: Living Water International

Country: Haiti

Method: CHC

More Methods!

• Many based on similar tools PRA tools, etc.

• Tools and materials available from sites such as Hesperian, CAWST, UNICEF and others.

• CCG – Community Care Groups (often more a MCH focus with specific H&S lessons included)

• Modified hygiene training in Disaster Response

Guidelines

• Modify: Make the method, tools, timing, etc. work for you

• Barrier Analysis: Established curriculum are great, but you can be more effective you figure out why people don’t do a practice

• Gospel: Hygiene training is a amazing venue for sharing the gospel

Children’s Hygiene and Sanitation

Proven Premise:

• Hygiene practices acquired in childhood

• Easier to change habits in children than adults

• Start them early!

Methodologies:

• CHAST

• SLTS

• CtC

• WASH in Schools (WinS)

• Many others

CHAST: Children’s Hygiene and Sanitation Training

• Developed in 2002

• Based on PHAST but directed toward children ages 5-12

• Utilizes educational games and activities

• Sessions of <30 children

• Weekly sessions for 6 months

SLTS: School Led Total Sanitation

• Developed in 2005 - Mobilizes child clubs to motivate communities to build and utilize latrines

• Built on elements of CLTS and uses similar approach

• Children encouraged to adopt hygiene and sanitation behaviors and become the agents of change in a community

• Dependent on the efficacy of teachers

CtC: Child-to-Child

• Rights-based approach to health promotion

• Educational process linking children’s learning to actions promoting good hygiene and development of themselves and others

• Typically components of another program, not a hygiene curriculum, per se

WinS: WASH in Schools

History:

Began in 1998 partnership of IRC, UNICEF and WHO

Significantly more emphasis on WinS in the last few years

WinS: Overview

• Both hardware and software components emphasized

• Students act as community change agents

• Aims at improved and maintained facilities as well as improved hygiene behaviors in schools and communities

• Previously known as SSHE-School Sanitation and Hygiene Education

WinS: Methodology

Programming typically includes:

• Hardware:

– Adequate water supply (construction of water point)

– Sanitation provision – toilet and urinals

– Hand washing stations

• Software:

– Administrators/Teachers: Trained to teach students

– Community/Parents: Trained school management committees

– Students: Active school WASH clubs

WinS: Strengths/Weaknesses

Strengths

• Uses existing network of schools to influence behavior change

• Direct benefit to children, especially girls

• Both hardware and behavior change

• Indirect benefit to community

Weaknesses

• Dependent on teachers who require training and materials

• Teachers at government schools often transitory and the knowledge lost

• Hardware component adds to cost

WinS: A Word from the Field

• Name: Zerihun Hailu

• Organization: Lifewater International

• Country: Ethiopia

• Method: WASH in Schools

Menstrual Hygiene Management

• Taboo subject

• Slowly gaining recognition that it needs to be addressed.

• Not a part of many “standard” curricula

• Include it in your programming!

– Education opportunities

– Suitable WASH facilities

– Microenterprise opportunities

(Background Photo: http://unibathlibrary.wordpress.com/2011/05/04/quiet-study-extended-during-revisionexam-weeks/)

Menstrual Hygiene Management

• Inability to manage menstrual hygiene (including physical pain and stress) hampers education prospects for girls and women

– 23% of girls drop out of school at menarche

– Depending on the community, 7-95% of girls skip school during menses

• Proper understanding about menstruation and resources for maintaining hygiene practices are lacking in many communities

– Dangerous practices

– Men know little about menstrual hygiene and typically perpetuate the silence and neglect

• Women have less control over their bodies and resources that help them care for themselves

– Typically lack the financial power or social status to impact decisions that improve their health

Educate on Menstrual Hygiene

• Implementation of menstrual hygiene education in schools

– Educational sessions on the biology of menstruation

– Distribution of informational booklets outlining the details of menstruation, addressing common misconceptions, and detailing stories from other girls’ experiences

(Booklet Cover Photo: Abdul Gugu)

MHM: Resources

Feminine Hygiene Around the World. 2014. Lipgloss and a Backpack. Access from: http://lipglossandabackpack.com/feminine-hygiene-around-the-world/

Paul S. 2014. Indian Girls Break Taboos on Menstrual Hygiene. Inter Press Service. Access from: http://www.ipsnews.net/2014/05/indian-girls-break-taboos- menstrual-hygiene/

Petronzio M. 2014. Half the World Menstruates. Now Let’s Talk About It. Mashable. Accessed from: http://mashable.com/2014/05/28/menstrual-hygiene-day/

Society for Menstrual Cycle Research. Access from: http://menstruationresearch.org/

WASH United. 2014. Menstrual Hygiene Day. Access from: http://menstrualhygieneday.org

________________________________________________________

*See bibliography of Menstrual Hygiene Matters manual. Access from: http://www.wateraid.org/what-we-do/our-approach/research-and-publications/view-

publication?id=02309d73-8e41-4d04-b2ef-6641f6616a4f&sc_lang=en

(Background Photo: WASH United/Himanschu

Khagta )

SanMark: Sanitation Marketing

• http://www.sanitationmarketing.com/resources

• http://wsp.org/toolkit/toolkit-home

Picture from: http://www.wsp.org/content/sanitation-marketing-helps-make-toilets-more-available-and-affordable

SanMark: Overview

• Market-based approach addresses demand and supply to increase uptake and use of improved sanitation

• Based on adapting the four Ps:

– Product: Latrine (or possibly a service like pit emptying)

– Price: Fully commercial or certain items subsidized for the most vulnerable

– Place: Supply chain to reach every household

– Promotion: Creating demand via promotion based on understanding of the target audience

SanMark: Methodology

Plan • Assess market and partnership conditions

• Plan and budget program

Research • Understand poor household consumers

• Understand businesses and supply chains

Design • Design affordable, desirable sanitation products/service options

Test Supply • Design and test supply chain and business models for product delivery

Test Demand

• Design and test promotional and marketing materials/tools/activities

Implement • Piloting and roll out of supply expansion and demand creation activities

Monitor • Monitor for results and equity

2-3 mo.

3-6 mo.

5-6 mo.

4-5 mo.

4-5 mo. (concurrent

with supply)

2-3 yrs.

2-3 yrs.

SanMark: Strengths/Weaknesses

Strengths

• Responds to changes in demand

• Builds local capacity

• Ideally sustainable business oriented approach

Weaknesses

• Support of businesses can distort the market

• Lengthy implementation time.

• Businesses not necessarily tied to commitment to ethical behavior

• Does it reach the most marginalized populations?

Questions?