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.
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)
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.
|Key WASH component||Priority behaviour||Target audience|
|Safe drinking water||Keep 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 containers||Women, men, children in homes without pipe connection|
|Cover drinking water container at all times||All residents|
|Fetch drinking water in a manner that does not put hands/fingers into drinking water, i.e. tap, long-handled ladle||All residents|
|Place drinking water container on a raised surface out of reach of small children||All residents|
|Use proven, effective methods to purify drinking water, i.e. boiling, purification tablets/sachets, filtration, solar heating||All residents|
|Clean containers used for transportation and storage of drinking water at least once a week||All residents|
|Latrine use||Use a latrine at all times (including for disposal of child faeces) and do not use open defecation||All 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 safely||All 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 defecating||All 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 place||All 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 regularly||All residents|
Some of these priority behaviours are illustrated in Figures 10.1 to 10.4.
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.
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:
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.
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.
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 10.7 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.
All these factors can lead to poor adoption of good hygiene and sanitation practice.
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.
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.
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:
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:
Now read Case Study 10.1 on open defecation and answer the question that follows.
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.
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?
To address socio-cultural barriers, social change communication (b) would be most appropriate because the behaviour change which is needed relates to social customs.
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.
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.
In Study Session 10, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions.
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.
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.
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:
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:
Which type of communication intervention would you recommend in order to improve Mana’s situation and why?