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Study Session 10 Promoting Improved Hygiene and Sanitation


You have learned in Study Session 2 that human faeces are the main source of diarrhoeal pathogens. They are the cause of many infections such as dysentery, ascariasis, schistosomiasis, cholera, typhoid and acute watery diarrhoea (AWD) (see Table 2.1 in Study Session 2). There is also growing evidence that diarrhoea is a significant contributory cause of stunted growth in children (Checkley et al, 2008).

The disease-causing pathogens that originate from faeces can be passed from an infected host to a new one via various routes. Promotion of practices that can prevent transmission of the pathogens that cause diarrheal diseases is therefore hugely important. These practices include handwashing with soap, proper handling of food and water purification. Where adequate sanitation is available coupled with improved hygiene behaviours, there can be dramatic reductions in the incidence of diarrhoea. Improvements can also be expected in other areas such as a cleaner environment, safer water and food, better nutrition and hence improved learning among school children and improved dignity and privacy for everybody, especially women.

This study session will focus on ways in which improved hygiene and sanitation can be promoted.

Learning Outcomes for Study Session 10

When you have studied this session, you should be able to:

10.1 Define and use correctly all of the key words printed in bold. (SAQ10.1)

10.2 List desired priority behaviours in the WASH context. (SAQ 10.2)

10.3 Describe the possible barriers that might prevent improvements to WASH practices. (SAQ 10.3)

10.4 Give examples of methods for promoting improved WASH practices in urban settings. (SAQ 10.4)

10.1 Selecting priority behaviour in the WASH context

You learned in Study Session 8 how to assess and analyse behaviour within a FOAM framework. Based on the findings from such an analysis, priority behaviours can be identified. These are behaviour changes that could contribute to an improvement in the health of the target population. The purpose of identifying priority behaviours in WASH is to assist in developing a focused behaviour change communication intervention that can contribute to sustainable change in the health condition of the population. Specific behaviours related to WASH will need to be addressed at individual, household and community levels.

The behaviour change strategy would also need to identify potential target audiences for the campaign. If there are inadequate resources to address every target audience at the same time, then some will need to be prioritised. For example, you might give priority to audience groups that comprise the largest proportion of the target population, or are identified as having high public health importance, or likely to be most receptive to communication messages.

Some key WASH related priority behaviours, and suggested target audiences, are presented in Table 10.1. These are just a few examples. In practice there are many other possible priority behaviours depending on the situation. You should select appropriate priority behaviours and target audiences based on a situation analysis for the community in which you are working.

Table 10.1 Priority behaviours and target audiences for key WASH components.
Key WASH componentPriority behaviourTarget audience
Safe drinking waterKeep water safe at source of supply

Private water vendors

Public stand pipe attendants

People who collect water from protected springs and wells

People who sell from their own wells

Always transport water in closed containersWomen, men, children in homes without pipe connection
Cover drinking water container at all timesAll residents
Fetch drinking water in a manner that does not put hands/fingers into drinking water, i.e. tap, long-handled ladleAll residents
Place drinking water container on a raised surface out of reach of small childrenAll residents
Use proven, effective methods to purify drinking water, i.e. boiling, purification tablets/sachets, filtration, solar heatingAll residents
Clean containers used for transportation and storage of drinking water at least once a weekAll residents
Latrine useUse a latrine at all times (including for disposal of child faeces) and do not use open defecationAll residents including those living in compound houses, in peri-urban areas, parents, guardians and carers of children under five years, carers of elderly or disabled residents
Dispose of solid waste generated at home safelyAll residents
Other home practices Wash hands with soap and air dry at the five critical times, i.e. before eating, after handling child‘s faeces, before preparing food, before feeding a child, and after defecatingAll residents, but especially parents, guardians and carers of children under five years, school children and anyone handling food
Sweep the house and surroundings daily and dispose of the sweepings in a designated placeAll residents

Cook food well

Wash vegetables well in brine (salt water)

Wash all utensils, containers, surfaces before preparing meat

Do not use the same surface for cutting meat and vegetables

Food vendors, restaurant owners, women, men, children
Clean yourself with adequate water and soap regularlyAll residents

Some of these priority behaviours are illustrated in Figures 10.1 to 10.4.

Figure 10.1 Supplying water in closed containers with secure lids.
Figure 10.2 Using closed containers is particularly important when there is stagnant water nearby.
Figure 10.3 Water purification tablets for household water treatment.
Figure 10.4 Washing hands with soap before eating at a restaurant.

10.2 Behavioural barriers to improving hygiene and sanitation

There are many difficulties with improving hygiene and sanitation; in particular there are many reasons why the behaviours listed in Table 10.1 may not be adhered to. These behavioural barriers differ from context to context. Results of a situation analysis used to complete the FOAM framework will help you to identify the most crucial WASH related behavioural barriers in your context.

The behavioural barriers may be the result of personal or socio-cultural factors, or may be due to service and infrastructure issues, or to economic or environmental factors. Here we present some of the most important WASH related behavioural barriers that you may encounter when conducting a situation analysis. Please note that the list is by no means exhaustive.

10.2.1 Personal barriers

Personal barriers include those resulting from lack of knowledge or awareness. For example, people may not be aware of the health dangers of contamination, and in particular that hands can contaminate water, and they may not know about all the critical times to wash hands. There may also be a lack of knowledge about appropriate disinfection procedures or of household water treatment and filtration devices and other products available, and limited awareness of the health dangers posed by decomposing waste.

People may not have the habit of regular bathing, or good handwashing behaviour because of a lack of time in busy households. It may also be that there is no scoop available in the household for moving faeces, or no jerrycan in the home to use for storing water.

Another personal barrier could be a perception that boiled or purified water has an unpleasant taste.

  • List the personal barriers to improved hygiene and sanitation that result from lack of knowledge or of awareness. Which three of these are the most important in your area? Which other personal barriers are particularly important in your area?

  • You might have included a lack of knowledge or limited awareness of:

    • health dangers of contamination
    • unwashed hands can contaminate water
    • all the critical times to wash hands
    • health dangers from decomposing waste
    • methods for household water treatment
    • products available for disinfection.

    The three that are most important will vary from one area to another but it is likely that lack of awareness of the health dangers, of the fact that hands can contaminate water, and of all the critical times to wash hands will be among them. Other important personal barriers might be that there is no habit of bathing or of good handwashing behaviour.

10.2.2 Socio-cultural barriers

There are a number of social and cultural or religious barriers which might prevent people from adopting good WASH behaviours. For example, many mothers believe that child faeces are harmless and hence they do not discard them properly. It is very common to see people washing their hands with only water even though soap is available. Figure 10.5 shows a woman cleaning a latrine – it is rare to find a man engaged in such activity, which may lead to lack of interest in the issues of cleanliness.

Figure 10.5 A woman cleaning a latrine.

There may also be a preference for water from natural sources for drinking due to perceived taste differences when water has been treated (Figure 10.6).

Figure 10.6 This boy, like many children in Ethiopia, drinks untreated water every day.
  • Figure 10.7 shows water that has been left in a church to be blessed. Can you identify the health risk here and the barrier that is involved?

  • The water has been left in a open containers, so could become contaminated. The barrier here is a religious one, arising from a belief that the water cannot be blessed unless it is in an open container. In the FOAM framework this is an ‘attitudes and beliefs’ determinant.

Figure 10.7 Water placed in a church to be blessed.

All these factors can lead to poor adoption of good hygiene and sanitation practice.

10.2.3 Service and infrastructure-related barriers

Some serious barriers in urban and peri-urban communities relate to issues of service and infrastructure (UNICEF, 2008). There may be inadequate sanitation and latrine facilities, in particular in schools. Public latrines are often not well kept and may be poorly ventilated and unclean, so people avoid using them because of an unpleasant stench. Moreover there are only a few child-friendly and disability-friendly latrines available. In households, there may be limited space for constructing latrines. Those who own houses which are rented may refuse to provide latrines. Poor ground conditions such as a high water table and loose soil may restrict design choices and technology options.

As for water supply, there may be an irregular flow of water in piped areas, and seasonal changes in water availability and quality. There may be high salinity or high fluoride content. Moreover there are often only a limited number of water sources, leading to long pipelines, and this can result in a long distance between water points and homes. Water points may be poorly maintained. There may also be limited availability of water purifying tablets or sachets.

With regard to waste disposal, municipal waste collection and sludge removal services may be absent or inadequate. Even if such services are present, they may be expensive. There may be only weak enforcement of municipal sanitation laws. In some urban areas, such as in Addis Ababa, litter bins are provided (Figure 10.8) but in others there may be no litter bins, or they may be expensive to provide, or rarely emptied. There may not be the appropriate vehicles available for removing sludge regularly from public latrine facilities.

Figure 10.8 Litter bin in Addis Ababa.

10.2.4 Economic barriers

A number of economic barriers exist for urban communities and these include the high costs of obtaining a household pipe connection (Figure 10.9) and acquiring a latrine facility, the cost of water, and the cost of soap. In places where handwashing facilities and soap should be available (near latrines and kitchens, and in restaurants), it may be too expensive to provide them. Moreover the cost of removing sludge and of refuse collection may be prohibitively high.

Figure 10.9 A pipe connection providing safe water for a group of households.

10.2.5 Environmental barriers

There are often environmental constraints to provision of adequate latrine facilities. For example, hard rocks increase the cost of constructing latrines because it makes it difficult to dig a pit. Sandy soils or marshy environments are not suitable for construction of latrines. High rainfall and/or recurrent flooding can pose significant barriers to construction and use of latrines (UNICEF, 2008).

The existence of bushes and open spaces around communities can be a barrier to use of improved latrines, as open defecation can be an easy alternative in such areas. Bushes and other weedy growth in open spaces also tend to promote indiscriminate dumping of waste, and so constitute a barrier to safe solid waste disposal.

  • Identify the most significant barriers which are likely to prevent WASH behaviour improvement in your community.

  • The most significant barriers may be different from one community to another but are most likely to be economic ones, as outlined in Section 10.2.4. You may have identified some of the following:

    • financial constraints in building a latrine
    • high cost of obtaining a household piped water connection
    • high cost of removing sludge
    • high cost of refuse collection
    • lack of or high cost of handwashing facilities at community latrines
    • high cost of water
    • high cost of soap, or unavailability of soap at community latrines.

10.3 Interventions to promote improved hygiene and sanitation

Based on the identification of barriers as outlined in Section 10.2, you can then plan appropriate interventions that aim to change people’s behaviour and practices. You learned about the four main approaches which are used to address such barriers in Study Session 9. A health promotion intervention or initiative is one that actively encourages positive behaviour, and is usually concerned with change that will occur over a relatively long period of time.

  • What are the four approaches to influencing behaviour that you learned about in Study Session 9?

  • The four approaches are individual behaviour change communication, social change communication, social mobilisation and advocacy.

A health promotion intervention would use these approaches for different purposes. Here are some examples of the aims they might be used to achieve:

  • Behaviour change communication aims to promote child-friendly pit latrines in households, water treatment at the point of use, handwashing with soap, proper household water treatment, safe storage and disposal of waste water and food hygiene.
  • Social change communication aims to increase community involvement in selecting appropriate design options for water and sanitation facilities, to change cultural beliefs and to promote community-led total sanitation (CLTS). You will learn more about CLTS in Section 10.4.
  • Social mobilisation aims to bring stakeholders together to promote social marketing strategies in water and sanitation, handwashing, utilisation of locally available materials for construction of sanitation and hygiene facilities, technologies suitable for environments that have unstable and/or rocky soil and to introduce low-cost handwashing technologies near latrines.
  • Advocacy aims to persuade decision makers to reduce the cost of clean water provision, to promote child, girl and disability friendly WASH services in schools, to improve maintenance of water points and to improve municipal waste collection services.

Now read Case Study 10.1 on open defecation and answer the question that follows.

Case Study 10.1 Open defecation

There are some communities in Ethiopia where people do not use a latrine even when one is available. This is because their tradition prohibits male and female members in the same household from using the same place to expel their faeces. It is culturally unacceptable for them to defecate on top of each other’s excrement. In particular the community considers the act of defecating on faeces of the household head or that of respectful community members as quite despicable. For example, children are not allowed to defecate on top of their parents faeces, and a wife would never defecate on top of her husband's faeces. This belief and practice has adversely affected the community's use of latrines and aggravated the widespread practice of open defecation.

  • Identify the type of barrier which best explains the issue raised in Case Study 10.1. Explain which of the following types of barrier it represents and why.

    • a.Personal
    • b.Socio-cultural barrier
    • c.Infrastructure
    • d.Economic
    • e.Environmental.
  • The barrier is related to culture and tradition so it is a socio-cultural barrier (b).

  • Which type of communication intervention do you think would be the most appropriate for overcoming such a barrier and why?

    • a.Behaviour change communication
    • b.Social change communication
    • c.Social mobilisation
    • d.Advocacy.
  • To address socio-cultural barriers, social change communication (b) would be most appropriate because the behaviour change which is needed relates to social customs.

10.3.1 Community-led total sanitation (CLTS)

Community-led total sanitation (CLTS) was mentioned in Study Session 9. It is a method for mobilising communities to completely eliminate open defecation by triggering collective behaviour change (UNICEF, 2008). In Ethiopia the name has been modified and you are more likely to come across ‘CLTSH’, which stands for community-led total sanitation and hygiene.

CLTS/CLTSH depends on raising awareness that everyone in the community is at risk of exposure to disease even if only a few people continue to defecate in the open. It has been successful in ensuring that all households gain access to safe sanitation facilities in many parts of Ethiopia. It helps communities to understand the negative effects of poor sanitation and empowers them to collectively find solutions to their sanitation situation. CLTSH is about bringing sustainable behavioural change. In general, it works best in villages that have enthusiastic leadership but it is also dependent on convincing everyone to change their behaviour. Besides leadership, many other local social, physical and institutional conditions affect the prospects for CLTSH.

CLTSH involves trained facilitators working with communities as they go through three phases of the process: pre-triggering, triggering and post-triggering phases (Kar and Chambers, 2008).

CLTSH pre-triggering phase

The facilitators must visit the selected kebele or kebeles prior to the community triggering. This visit is mainly to estimate the size of the community and its population but also to identify the dirtiest areas in the vicinity that are most frequently used for open defecation. This must be done with the community, possibly using a participatory mapping process, as shown in Figure 10.10. They also decide on the most appropriate season and place to conduct the community triggering.

CLTSH triggering phase

Community triggering happens at a gathering of the local inhabitants who come together to have a dialogue about concerns related to open defecation. The purpose of this dialogue is to bring collective action against the open defecation behaviour. Triggering refers to the moment when the whole community shares a sense of disgust and shame about open defecation. The facilitator helps them to come to the realisation that they quite literally will be eating one another’s shit if open defecation continues.

In particular, the aim of the triggering phase is to reach agreement about actions to be taken. The actions will be governed by bylaws developed by the community. The final output of triggering is a community-based action plan, which includes an agreed schedule and set of activities that everyone in the community commits to participating in. This involves construction of latrines with handwashing facilities and commitment from everyone that they will use the new facilities at all times.

CLTSH post-triggering phase

After the community-based action plan is prepared, the community members must put the plan into action. They develop bylaws to ensure the elimination of the practice of open defecation in their community. The plan also states who will implement and enforce the bylaw.

In this phase, participatory review meetings should be organised by community members and facilitated by Health Extension Workers or other CLTSH-trained facilitators. The main purpose of these sessions is to review the progress made towards achieving the objectives of the plan. A sanitation map prepared during triggering can be used again to follow the progress made (Figure 10.10). Households that have constructed and started using a latrine are marked on the sanitation map. Comparing this with the original map can show the progress made in the reduction of open defecation sites.

Figure 10.10 Producing a sanitation map using a community participatory approach.

10.4 Sustainability of behaviour change

Sustainability means ‘able to last or continue for a long time’ (Merriam-Webster online dictionary). So the sustainability of a certain behaviour means that the ability of an individual to maintain that behaviour (in this case a hygiene and sanitation behaviour) for a long time. Ideally the behaviour change becomes a habit, something that is so familiar it is routinely practiced correctly, without variation and without thinking.

Behaviours are complex. Physical, social, cultural and institutional contexts shape and constrain people’s choices and options and hence their behaviour. The desire to target attitudes and behaviours using education and awareness-raising still remains strong. However, these measures tend to have little or no influence on behavioural shift if they run counter to other powerful incentives, such as prices or social norms.

Adopting a sustainable behaviour is the ultimate goal of hygiene and sanitation promotion interventions. You will learn more about sustainability in Study Session 13.

Summary of Study Session 10

In Study Session 10, you have learned that:

  1. Priority behaviours should be identified in order to develop a focused behaviour change intervention that can contribute to sustainable change in the health condition of the urban population. Specific priority behaviours for WASH interventions should be selected based on a situation analysis.
  2. Behavioural barriers differ from context to context. Results of a situation analysis help identify the specific WASH-related behavioural barriers.
  3. Behavioural barriers may include personal, socio-cultural, service and infrastructure, economic and environmental barriers.
  4. Based on behaviour analysis, a combination of four main intervention approaches may be pursued to increase, encourage and sustain a change in sanitation hygiene and health practices – individual behaviour change communication, social change communication, social mobilisation and advocacy.
  5. CLTSH is a method for mobilising communities to completely eliminate open defecation by triggering collective behaviour change. It is divided into pre-triggering, triggering and post-triggering phases.
  6. The ultimate goal of WASH promotion interventions is for them to be sustainable.

Self-Assessment Questions (SAQs) for Study Session 10

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions.

SAQ 10.1 (tests Learning Outcome 10.1)

Rewrite the paragraph below using terms from the list provided to fill the gaps.

behavioural barriers, community-based action plan, CLTSH, health promotion intervention, open defecation, priority behaviours, sustainable.

When planning a ……………… in a community it is important to identify the ……………… that can make a difference to the health of the target population. You also need to be aware of possible ……………… that may present challenges for your plan.

……………… aims to improve hygiene and sanitation behaviour by helping communities to realise the health risks from ……………… so that they all make a commitment to change their behaviour. During the process they prepare a ……………… that describes the activities and schedule for building new latrines. It is important to check for ……………… change by having regular reviews of progress to ensure that the improved practices of latrine use and handwashing continue into the future.


When planning a health promotion intervention in a community it is important to identify the priority behaviours that can make a difference to the health of the target population. You also need to be aware of possible behavioural barriers that may present challenges for your plan.

CLTSH aims to improve hygiene and sanitation behaviour by helping communities to realise the health risks from open defecation so that they all make a commitment to change their behaviour. During the process they prepare a community-based action plan that describes the activities and schedule for building new latrines. It is important to check for sustainable change by having regular reviews of progress to ensure that the improved practices of latrine use and handwashing continue into the future.

The remaining SAQs are based on the following case study. Read Case Study 10.2 about menstrual hygiene and then answer the SAQs which follow.

Case Study 10.2 Menstrual hygiene

Like many parents in Ethiopia, Selam does not discuss menstrual hygiene with her daughter, Mana. She is not willing to provide Mana with sanitary towels even though the family has no shortage of money. Selam believes that menstruation is not something that should be discussed openly with her daughter. Because Mana lacks the knowledge and the material to manage her menstruation properly, she misses up to five school days every month. Her school does not have separate latrines for girls and boys because of shortage of budget. During her period, Mana generally tells her teachers that she is sick and stays at home. At home, she tells her mother that there are no classes. This is adversely affecting her performance at school.

SAQ 10.2 (tests Learning Outcome 10.2)

Identify two priority behaviours which are important to try to change to improve the chances for girls like Mana to successfully complete her education.


You may have identified two of the following three priority behaviours:

  • Mothers should openly discuss menstruation with their daughters, since it is a normal feature of female physiology and nothing to be ashamed of.
  • School girls should be provided with sanitary towels and be taught about menstrual hygiene management.
  • Schools should prioritise the building of separate latrines for girls and boys.

SAQ 10.3 (tests Learning Outcome 10.3)

What are the personal, cultural and infrastructure barriers which might prevent the change of such behaviours?


These are among the examples of behavioural barriers you might have thought of:

  • Personal: Lack of proper knowledge about menstruation, negative attitude towards open discussion, lack of appreciation of the advantages of providing daughters with sanitary towels.
  • Socio-cultural: A culture of silence about menstruation.
  • Infrastructure: Unavailability of separate latrines for girls in schools, shortage of budget for providing separate latrines or for providing sanitary towels at affordable prices.

SAQ 10.4 (tests Learning Outcome 10.4)

Which type of communication intervention would you recommend in order to improve Mana’s situation and why?


  • Behaviour change communication could help to increase awareness about menstruation, encourage mothers to talk to their daughters about menstruation and encourage them to provide their daughters with sanitary towels.
  • Social change communication, such as community conversation, would help to change attitudes and social norms about menstruation.
  • Social mobilisation to all stakeholders in support of constructing separate latrines for girls in schools.
  • Advocacy to convince decision makers to allocate budget for constructing separate latrines for girls in schools and to subsidise the price of sanitary towels.