Towards Better programming A manual on hygiene promotion
Item
- Title
-
Towards Better programming
A manual on hygiene promotion - extracted text
-
unicefS
Technical Guidelines Series
United Nations ChiKiren’s Fund
Programme Division
Towards boner nrogramming
f
;-rrr- •
A Manual on Hygiene
Promotion
I
I
Illi
1 '•
■
■7:; \
' ■' " '
In collaboration with:
I
LONDON SCHOOt
orinKacNtA.
TROfTCA L MEDtCINE
Water, Environment and Sanitation Technical Guidelines Series - No. 6
Water, Environment and Sanitation Technical Guidelines Series No. 6
■ I
Towards Better programming
if
d
A manual on hygiene promotion
United Nations Children’s Fund (UNICEF)
The London School of Hygiene and Tropical Medicine (LSHTM)
1999
Water, Environment and Sanitation Technical Guidelines Series No. 6
A manual on hygiene promotion
© 1999
United Nations Children’s Fund
3 United Nations Plaza, TA-26A
New York, N.Y. 10017
A publication of UNICEF
Programme Division
Water, Environment and Sanitation
Document No. UNICEF/PD/WES/99-02
This manual on hygiene promotion is one of the Technical Guidelines Series prepared by the Water, Environment and
Sanitation Section, Programme Division, UNICEF. It was developed in collaboration with die London School of
Hygiene and Tropical Medicine. Titles of other publications in this series are printed on the inside back cover of this
Manual.
Any part of this document may be freely reproduced with the appropriate acknowledgement.
versions of this document will also be available.
For further information please contact:
UNICEF
Water, Environment and Sanitation Section
Programme Division,
3 United Nations Plaza, TA 26-A,
New York, New York. 10017. USA
Tel. (212) 824-6669
Fax (212) 824-6480
e-mail: wesinfo@unicef.org
or visit our Web site: http://www.unicef.org/programme/wes
2
Spanish and French
I
I
PREFACE
This manual is part of a series that aims to help implement the WES strategies approved
by the UNICEF Executive Board in 1995. These strategies emphasize a catalytic approach
in WES programming, where UNICEF support serves to strengthen each country’s learning,
programming and policy development process rather than to simply provide direct services.
This ‘catalytic’ role, it is hoped, will help produce greater benefits on a more sustainable
basis.
UNICEF Programme Division is pleased to present this Hygiene Promotion Manual as
part of its guidelines series on water, the environment and sanitation. This manual was
produced for UNICEF by the London School of Hygiene & Tropical Medicine in co-operation
with the Government of Burkina Faso. The manual is based on the experiences of the
UNICEF-supported Saniya Project, a public health communication project in a West African
town.
This manual presents methodologies to assist development workers in the promotion of
behavioural change for safer hygiene practices, and to help make hygiene promotion
programmes more effective. The objective of the manual is to provide a tool that will
contribute towards a reduction in diarrhoeal diseases - one of the top three killer diseases
in developing countries - and thus a reduction in child mortality.
The manual describes a methodology for bottom-up programming for hygiene promotion:
first finding out what people know about hygiene through formative research in people’s
knowledge and practices, and then combining this with state-of-the-art expert knowledge
and appropriate communication strategies to develop effective and sustainable
programming models. The manual is accessible and jargon-free: its audience includes all
professionals interested in the area of hygiene promotion.
This manual is only a beginning. We look forward to receiving suggestions and ideas on
how to improve this manual in particular, and to strengthen our hygiene programmes for
children in general. Also let us know which parts of the manual you find most useful, and
which parts, pages or paragraphs you find confusing, least useful, incorrect or unfair. We
are particularly interested in adaptations you had to make in order to match with the specific
socio-cultural conditions in your specific countries.
We look forward to receiving suggestions and ideas on how to improve this manual in
particular, and to strengthen our hygiene programmes for children in general.
Sadig Rasheed
Director
Programme Division
UNICEF New York
May 1999
3
ACKNOWLEDGEMENTS
This publication is the product of broad consultation and collaboration. The UNICEF
Programme Division would like to thank Ms Valerie Curtis, Lecturer in Hygiene Promotion
at the London School of Hygiene & Tropical Medicine and Ms Bernadette Kanki, Co
ordinator, Programme Saniya, Burkina Faso, who created this document.
The production of this manual was funded by UNICEF, in co-operation with the London
School of Hygiene & Tropical Medicine, the Ministry of Health, Burkina Faso, WHO, the
Centre Muraz (OCCGE) and the British Department for International Development.
Special thanks are due to Sandy Cairncross, Lizette Burgers, Ibrahim Diallo, Michel
Nikiema, Raphael Gbary, Hubert Barennes, Simon Cousens, the staff and fieldworkers of
Programme Saniya in Burkina Faso and AnkurYuva Chetna Shivir in India. Illustrations
were drawn by Mamadou Traore and Emmanuel Nkobi.
Thanks also go to T V Luong, Silvia Luciani, as well as a number of UNICEF colleagues in
the field offices whose comments were very helpful in revising the document.
Finally, to all those too many to name whose contributions have made this a better
publication, Programme Division extends its grateful thanks.
4
I
fl
I
I
Contents
Introduction:
New Ways of Promoting Safe Hygiene
Chapter 1:
What is Hygiene Promotion?
Chapter 2:
Six Steps to Hygiene Promotion
Chapter 3:
Risk Practices
Chapter 4:
Practices to target
Chapter 5:
Motivating Behaviour Change
Chapter 6:
Communicating Hygiene
Conclusion:
Hygiene Promotion: Practical and Effective
5
INTRODUCTION
New Ways of Promoting Safe Hygiene
Why hygiene?
Diarrhoea is one of the top three killer diseases in developing countries,
claiming the lives of more than three million children a year.
Improvements in water supply and sanitation in the last 20 years have
helped to cut the incidence of diarrhoea. But if these technologies have
had an impact on health, it is because they make better hygiene
possible.
Whether modern facilities are available or not, the best way to protect
a child from diarrhoeal diseases is to keep the child's living space free
of the microbes that cause diarrhoea. That means adopting a number
of safe hygiene practices in and around the home.
What is this book about?
This book shows how to encourage people to adopt safer hygiene
practices. They can also help you to make your current hygiene
programme more effective.
In this step-by-step guide we:
0
0
0
6
show how you can work
with communities to learn
what people know, do and
want concerning hygiene
offer you up-to-date ideas
about hygiene and communi
cations
explain how to put these to
gether to plan an effective
hygiene promotion prog
ramme
for
large
:l
Who is this manual for for?
'I
!l
If you are a:
0
0
0
0
Decision maker, team leader, manager, trainer or health worker
Working in Government, aid agencies or NGOs
In the field of health, water supply, sanitation or urban services
In urban or rural settings.
Then this book is for you!
I
I
How to use this manual
There are six Chapters in this book.
Chapter 1 answers the question, what is hygiene promotion?
Chapter 2 outlines the steps in setting up a hygiene promotion
programme.
Chapter 3 describes what we know about the practices which put people
at risk of diarrhoea.
Chapter4 shows how to work with people to design safe alternatives to
the risk practices.
Chapter 5 describes how to identify what motivates people to carry out
safe hygiene practices.
Chapter 6 shows how to find out how people communicate and how to
use this to design an effective hygiene
communication programme.
I
I
The maual has been kept short
and simple, and is in black and
white so that you can photocopy
pages. We have minimised the
technical jargon, but you may find
some key words you have not met
before. Definitions can be found in
the glossary at the end.
Chapter 1
What is Hygiene Promotion?
Hygiene promotion is a new way of encouraging practices to prevent
diarrhoeal disease in the home. This chapter describes the background
to this approach and the advantages that it has over hygiene education,
which has been a standard approach until now.
I
I t
II
I
d
9
What is Hygiene Promotion?
Hygiene Promotion is a planned approach to preventing diarrhoeal
diseases through the widespread adoption of safe hygiene practices.
It begins with, and is built on what local people know, do and want.
The diagram shows how the planning team works together with
representative communities in a process known as formative research.
The aim is to answer four key questions: which specific practices are
placing health at risk? what could motivate the adoption of safe
practices? who should be targeted by the programme and how can
one communicate with these groups effectively?
Feasible
target
practices
What are high
risk practices?
Who carries out
the risk
practices?
What is liked
about the
replacement
practices?
0
/what the\
/community \
/ knows,
\
/ does, wants \
\ What the hygiene/
\ worker knows /
How do people
communicate?
Community
0
Target
audiences
Message
positioning
Communications
plan
Formative Research
Hygiene Promotion
Plan
This manual shows how to go about answering these questions to
design a full scale hygiene promotion programme in collaboration with
key stakeholders. Simple, positive and attractive messages are
designed for local channels of communication. Measurable behaviour
change objectives are set, and management, monitoring and evaluation
goals complete the hygiene promotion programme.
10
Background to this manual
The new approach to diarrhoea prevention that we call hygiene
promotion grew out of a series of detailed studies in the town of BoboDioulasso in Burkina Faso. The aim of the work was to find effective
ways of preventing diarrhoeal disease in children. What we learned
about what people did showed us that hygiene was a major problem.
What we learned of what people believed and wanted showed us that
standard approaches to encouraging behaviour change would not work.
We looked around for solutions, and when none seemed suitable,
realised that we would have to find a new way. Nine years from the
start of this work, the new approach has been tested succesfully in
Africa and India. It has been much written and taught about, and has
been enriched in the process (Curtis et al). Finally UNICEF provided
support for the London School of Hygiene & Tropical Medicine to
condense the lessons and experiences into this manual so that hygiene
promotion can be applied more widely in the field.
Of course, we do not claim to have provided a perfect solution; changing
hygiene behaviour will never be quick or straightforward. Neither do
we claim exclusive use of the term ‘hygiene promotion’, which is now
becoming widespread. Theoretical and practical refinement of the
approach we describe in this book will continue with the help of readers,
practitioners and fellow researchers. So please do send us your
comments and suggestions.
What is new about this approach?
Though few of the features of hygiene promotion are new, the idea of
combining them into a simple, step-by-step planned approach is. It
draws on a synthesis of practical and theoretical lessons from
anthropology (the need to see the problem through the eyes of the
people concerned), epidemiology (careful identification of risk
practices), marketing (motivation research), communication (planning
for reach and effectiveness) and development studies (participatory
rural appraisal).
11
Why do we need a new approach?
Everybody working in preventive health knows that getting people to
change the habits of a lifetime is not easy. Though health education
has been largely abandoned, or renamed ‘health promotion' in the West,
it is still the standard approach in developing countries. Several reviews
of the effectiveness of health education point to very disappointing
results (Loevinsohn). One reason for this poor performance is the topdown approach, that fails to respond to what people know,do and want.
Another reason is that education is often tacked on as an afterthought
in water, sanitation and health programmes; it has low priority and has
little claim on management time and programme resources (Burgers).
On the next two pages we outline some flaws of the old model of hygiene
education.
Beyond the KAP study
If programmes have often been top-down, it is at least in part because
we have not had good techniques for finding out what people know, do
and want, on which to base our programmes. The limits of the KAP
(Knowledge, Attitudes, Practices) study are well known. Respondants
in KAP surveys often tell the interviewer what they think she wants to
hear, or what they think will bring the greatest benefits (Kroger).
Interviewing about hygiene is of little use because of the sensitivity of
the subject. However, over the last decades, there has been an
explosion of interest in methods which can dig deeper and produce
more insight into health problems. Qualitative techniques such as focus
groups and participant observation are now taught in most schools of
public health. What has been lacking is a systematic approach which
links key questions to appropriate methods to inform programme
design. This is what we have attempted to do in this manual.
We call this systematic approach formative research. It has also been
used to find out what people want in a bed net treatment programme
for the prevention of malaria in Burkina Faso. Formative research could
be used to provide information for the effective marketing of sanitary
latrines or for designing village water supply programmes.
12
Six Myths of Hygiene Education
The way in which hygiene education used to be carried out had very
poor results. This was partly because it was founded on a number of
myths.
Myth No 1. People are empty
vessels into which new ideas can
simply be poured
Hygiene Education rarely starts with
what people already know. Every
society already has coherent
explanations for disease (which may
or may not include microbes). If we
try to pour new wine into these already
full vessels then, the new wine will just
spill over. The new ideas create
confusion and incomprehension.
Some people even reject the new
teachings saying: “these doctors just
don’t understand what makes my
child sick!"
P I'
Myth No 2. People will listen to me because I’m medically trained
Hygiene Education often assumes that health personnel are automatically
believed and respected. This is often untrue in both developed and
developing countries. There is no reason why the outsider with the foreign
ideas should be given higher credence than tried and tested local
explanations of disease. And a health worker who is thought to be saying
“it's your fault your kids get sick and die, it’s because you are dirty" will
gain little respect from the community (Nations).
Myth No 3. People learn germ theory in a few health centre sessions
Everybody likes to learn, but how responsive would you be if you were
worrying about a sick child in a clinic waiting room? Even in the best of
circumstances, replacing old ideas about disease with new ones is a
long, slow process.
13
Myth No 4. Health education can reach large populations
Major improvements in public health require interventions that cover
large populations, like vaccination or AIDS prevention programmes.
But is it practical to give health education classes about the germ theory
of disease to all the childcarers in a region? Lets take an example; say
we want to educate the mothers of one province about the role of
microbes in diarrhoeal diseases. The population is 800,000 people,
there are 200,000 mothers, each of whom need to attend a minimum
of three group sessions. If one educator can carry out three sessions
per day, 100 educators will be required working flat out for a year. Few
health programmes would find this practicable.
Myth No 5. New ideas replace old ideas
Most people hold a variety of ideas about the origins of disease in their
heads at the same time. Folk models of illness co-exist with medical
models in all countries of the world, and few people anywhere explain
child diarrhoea by lapses in stool hygiene. Hygiene education often
just adds one more idea about disease without erasing the old ones.
Myth No 6. Knowing means doing
Even if we could convince large populations that germs spread by
poor hygiene cause disease, would this mean that they would change
their practices overnight? Though knowing about disease may help,
new practices may be too difficult, too expensive, take too much time,
or be opposed by other people. Fear of disease is not a constant pre
occupation and is often not a good motivator of behaviour change.
(These myths are adapted from the useful booklet by Van Wijk & Murre.)
The best health education practice does not make all these mistakes.
Unfortunately, in the field of hygiene they are still very common. Of
course everybody has a right to know as much as possible about health.
In particular, every child in school should have the opportunity to learn
health science. (School hygiene programmes are a separate subject
which are not covered in this book). But we cannot assume that
education about germs and diarrhoea will lead directly to behaviour
change, or have a major impact on diarrhoeal diseases.
14
SI
Instead of...
Starting in an office...
Using only what I know...
Lecturing about germs, dirt and
disease...
Communicating in the way that
suits me...
Hygiene promotion...
Starts in the community
Finds out about the problems
Finds out why people want good hygiene
Builds on how people communicate
peeq unoA uo Buipuejs uoijoiuojd auaiBAn
Chapter 2
Six Steps to Hygiene Promotion
In Chapter 1 we saw why a new approach to hygiene promotion was
needed. Here we take you through the process of designing a hygiene
promotion programme, by planning and carrying out formative research.
We offer some examples and some practical tips.
t5
£
17
Six Steps to Hygiene Promotion
This chapter takes you through the steps in designing a hygiene promotion
programme. In step 1 action with the target communities and the team is
initiated. In step 2 a detailed work-plan for the formative research is made. In
step 3 the formative research is carried out. Step 4 is to analyse and report on
your results. In steps 5 and 6 the results are fed back and discussed with key
stakeholders and used to make the hygiene promotion plan. We conclude the
chapter with practical advice on sample sizes and teamwork.
STEP1. INITIATE ACTION
Define the target area. Find out what you can about it (maps, population,
administration, health services, (etc).
Make an outline plan, arrange for funding If you are planning a sanitation/
hygiene programme you should set aside funds for the formative research
separate from the main programme. Many donors are keen to fund well
thought out hygiene initiatives at present.
Set up the team. Borrow or employ staff, include women and men who
live in or come from the target area. You might need 4-5 fieldworkers and
a team leader. Project managers, staff and partners can all participate. If
you don’t have experience with research ask a local university or an agency
if they can provide advice.
Hold a planning workshop. Discuss what you already know about hygiene
in your target zone with the whole team. Share this manual, decide how to
adapt the approach to your circumstances. Health workers often think that
they already know all about hygiene practices, but don’t jump to conclusions
at this stage. Remember, the aim is to listen to, and learn from the targeted
groups, not to design your programme in your office. Choose a number of
sites that are representative of your target area and make a detailed work
plan together.
Contact the communities: where you plan to start work, meet with leaders,
administrators, women’s groups, use local media to let people know what
is happening. Propose the setting up of a community liaison committee to
advise you and to inform local people.
Build a network: Inform any other organisations working in the area, invite
them to join the programme. They may be reluctant at first, but when they
see the results they will probably want to join in.
18
PLAN OF FORMATIVE RESEARCH TO DESIGN A HYGIENE PROMOTION PROGRAMME
Objective
Chapter
Questions
3
Which specific practices are allowing
diarrhoeal pathogens to be transmitted
to children?
Epidemiological
knowledge,
Environmental walk
Checklist observation
4
Which risk practices are most
widespread?
Which risk practices can be altered?
Determine
message
positioning
5
What motivates those who currently
use ‘safe’ practices?
What are the perceived advantages of
the 'safe' practices?
Structured observation
Behaviour trials
Focus group discussions
Focus group discussions
Interviews with ‘safe
practicers’
Behaviour trials
Define the
target
audiences
6
Who and how many employ the risk
practices?
Who influences the primary audience?
Structured observation
Focus group discussion
6
What channels are currently used for
communication?
What channels are trusted for such
messages?
Interview representative
sample of target audience
Focus group discussion
Identify risk
practices
Select practices
for intervention
Select
communication
channels
co
Methods
STEP 2. MAKE A DETAILED FORMATIVE RESEARCH PLAN
The objective of step 2 is to make a detailed research plan like the one
shown on the previous page. It includes the four key questions of page
4 and some others. This table is at the heart of formative research for
hygiene promotion. It sets out the questions and identifies suitable
methods for answering them.To produce your own version, you need
to decide on your research questions, then find methods which are
suited to answering them. The table shows which chapters will help
you with which questions. You may know other methods you can use
to answer your questions reliably.
Make a list of questions you want to answer. This is best carried out
as a team exercise. Together cut the list down to only those that are
really important for the hygiene promotion. You will probably need to
answer all the key questions in the facing table and you may have
others. But do not make the list too long or your formative research
will become unmanageable.
Choose methods to answer each question. When you have your key
questions, choose a suitable method for answering each question.
Questionnaires may be a good way of finding out about channels of
communication employed by the population, for example, but they cannot
tell you about the frequency of risk practices. The relevant chapters go
over these methods in detail. Your own plan may differ in a number of
ways from the one shown. However, the principles remain the same.
Putting it all together. With the research activities listed out, you can
now work out the sample sizes (see p 27). In some cases you can
answer several questions in one go. For example, you could ask family
members about their radio and TV listening and market-going habits
after the morning structured observations. Make a detailed research
plan and assign responsibility to team members to carry it out.
Training the team. The formative research team will learn much of
what they need to know by participating fully in the development of the
research. Some formal training will be needed, especially in practicing
observing, interviewing and running focus groups. Hygiene Evaluation
Procedures (Almedom) has an excellent chapter on training.
20
STEP 3. CARRY OUT YOUR FORMATIVE RESEARCH
Identify risk practices, select practices for intervention. You can work
out which practices are posing a problem in your area if you start from the
idea that most diarrhoea pathogens come from stools. Any practices that
allow faecal material into the child’s environment, especially stools on the
ground and poor hand-washing after stool contact are likely to be a priority
for action. The risk practices that occur most frequently are a priority for
intervention. Behaviour trials allow you to work with target communities
to choose suitable replacement practices. Chapters 3 and 4 give detailed
guidance.
Define message positioning. This is discussed in Chapter 5. Briefly,
it means finding out from your primary target audience what they like
about the target practices. This can be done by interviewing people
who already use the safe practices, and in focus groups and interviews
after people have tried out the practices for a few weeks.
Communication strategies are then built around these positive values.
For example: ‘hand-washing with soap makes your hands smell good.’
Define the target audiences. These are the groups you want to contact.
Primary target audiences are those who carry out risk practices (for
example, mothers, school children). Secondary target audiences are the
immediate society of the primary audience who influence them (eg fathers,
school children, mothers-in-law). There is a third target audience which is
very important: opinion leaders such as religious, political, traditional
leaders and elders. They can have a major influence on the success of
your programme, as can partner and collaborating agencies.
21
Each segment of your audience can be addressed separately, so while
you may arrange for house-to-house visits to reach mothers, street thea
tre may be more effective in reaching fathers and youths, and leaflets
might be appropriate for partner agencies. Chapter 6 gives more detail.
Identify communication channels. By finding out how many of the
target audiences read papers, listen to the radio (and when), belong to
social groups, etc, you can see which channels are most suitable for
hygiene messages, (see Chapter 6)
If all goes well and you have good planning, adequate resources and
logistics, you should be able to complete your formative research in less
than three months. There is a list of practical tips for managing the work
on page 26.
STEP 4. ANALYSE RESULTS, REPORT AND FEEDBACK
Summarise the data that you have gathered in tables. Go back to your
preliminary set of questions and try to answer them from your data.
Then write a short, attractive report describing:
O
Your objectives
0
The methods that you used
0
The results that you got
0
Your interpretation of the results
0
Your recommendations for hygiene promotion
You can get a local artist to do some simple illustrations and give it an
attractive cover. If you use only black and white text and illustrations
the report can be photocopied easily. Many of your readers will be
administrators who have too little time to read, so make sure that your
report is short and clear and that it stands out!
Distribute the report widely. Ensure that all potential partners have
copies. Translate the report into local languages and give plenty of
copies to the participating communities. It is worth making several
hundred copies as this is an important part of the consultation process.
Hold public consultations and workshops with partners.
22
STEP 5. MAKE THE COMMUNICATION PLAN
Involve people from the community and partners who had good ideas
during the consultation process. Get together for several days to work
on the full-scale plan for the hygiene promotion programme. Make a
plan with the following elements:
0
0
0
0
0
0
0
0
Behaviour change objectives: for example ‘Hand-washing with
soap after cleaning a child’s bottom will go from 5% of occasions
to 35% in two years’.
Target practices: the key hygiene practices that replace the risk
practices
Target audiences: age, sex, number in each group
Positioning: Motivation for behaviour change (why do target
audiences want the new practices?)
Channels of communication: for example, street theatre, house
visits, radio, schools.
Communication materials: the supports you develop for your
communications activities like theatre scenarios or flash cards.
Monitoring: methods for following progress in programme activi
ties, indicators, programme outputs, and in behaviour change
Project management and budget.
You can get ideas and help
with designing communication
materials from a local publicity
agent or advertising agency, or
from local artists, writers and
musicians. The communication
activities are based on the
target practices and
motivations and are designed
for each target audience. They
are tested and revised before
being used at full scale
(Chapter 6).
23
STEP 6. SET UP AND RUNTHE HYGIENE PROMOTION PROGRAMME
Pilot, test and revise everything. Your hygiene promotion programme
will start off best with a few months of testing of messages, strategies
and communication materials on a small scale, so that they can be
refined and improved, before you begin a large-scale operation.
Hold focus groups to review radio spots or theatre scripts. Ask women
visiting clinics to tell you what they see in any images or visual supports
you produce. If you decide to work in schools, try out your schools
programme in one school first. Ask teachers and children what they
liked and what they didn’t like about the programme and then modify it
accordingly. Any materials you produce such as posters or radio scripts
will certainly need to be tested and revised, probably several times,
before you adopt them. (See Chapter 6.)
Carry out a baseline survey of target behaviours. Using the same
structured observation technique that was used in the formative
research to identify risk practices, take a sample to represent of the
target group and observe the target behaviours. Duplicate surveys are
then used later to monitor progress towards project objectives.
Set up supervision and monitoring. In common with all development
programmes, health promotion activities need to be carefully supervised
and monitored. Periodic reviews will allow you to ensure that your
activities are being carried out, that they are reaching people and that
they are effective. The results will allow you to modify the programme
to make it more effective.
Evaluate. Evaluation will allow the experience to be improved upon,
extended and transferred elsewhere.
Example: Look carefully at the table on the next page; it shows the
research questions, the methods that were used to answer them, the
answers that were found, and how these translated into programme
decisions in a town in India. Whilst your formative research may ask
different questions and will get different answers, the logical process is
the same. Formative research guides the programme design.
24
FORMATIVE RESEARCH TO DESIGN A HYGIENE PROMOTION PROGRAMME IN LUCKNOW, INDIA
U1
Research
questions
Methods used
Key findings
Key findings
What are the
risk practices?
Environmental
walk,
Checklist
observation,
Structured
observation
Defaecation of most small children
was on the ground. Mothers did
not wash hands with soap after
cleaning up the child.
Few people returning from toilet
washed hands with soap.
Risk practices: unsafe
disposal of child stools.
Infrequent hand-washing with
soap after stool contact.
What are the
target
practices?
Behaviour
trials,
Structured
interviews
The ordinary soap cannot be used
after defaecation as it becomes
polluted.
Using community latrine not
acceptable, no use for children.
Potties liked by mothers.
Target practices:
A special piece of soap is
kept for hand-washing
after defaecation. Local latrine
building programme contacted.
Potties bought for children.
Who are the
target groups?
Observation,
Focus group
discussions
Mothers deal with child stools.
Mothers and fathers do not use
soap after stool contact.
Motner-in-lawand husbands
influence mothers
Target groups:
Primarylarget: mothers.
Secondary target: fathers, and
mothers-in-law.
What motivates
behaviour
change?
Focus groups,
Structured
interview
Desire to be clean, pure and
auspicious.
Desire to save time cleaning up
children.
Desire to please family and God.
How do people
communicate?
Interviews,
Focus groups
No one channel with good reach.
Some mothers had little contact
with outside world.
Motivation:
Hand-washing with soap after
stool contact makes you clean
and pure.
Potties save time and effort.
Variety of channels: street
theatre, house-to-house visits,
religious gatherings.
Practical
Tips
Pitfalls and problems
Following this logical process through from asking key questions, to
working with the community to answer them and then using the answers
to design the programme may seem straightforward, but there are a
lot of points at which things can go wrong. Formative research is not
always easy. The advice of someone who knows how to carry out
focus groups or structured interviews can be invaluable if you have
not done it before. The most important skill you need is to pick out
those questions that most need answering, and then to pursue the
answers until you are convinced that you have learned what people
really think, want and do. Discussing your results with the communities
and working with them on the programme design should ensure that
you do not go too far wrong.
Depending on where you work, your biggest difficulty may be to get
institutions, programmes and collaborators who are used to health
education to change to a promotional approach. Sometimes it is harder
to change the behaviour of the ‘experts’ than that of the population!
The only solution is to invest in training, activities to build ‘like
mindedness’ and, if necessary, to be prepared to compromise.
There is an apparent paradox at the heart of hygiene promotion
programmes that can be hard to deal with. Whilst the hygiene promotor
sets up the programme for the sake of better public health, the
community may be more interested in hygiene for the sake of the
pleasure of cleanliness or the convenience of the target practices. It
will seem strange to some people that the programme focuses on
aesthetics and comfort rather than germs and disease. Team members
often slip back into the old ways of educating about germs and giving
negative messages about death and diarrhoea. Whilst education about
germs is a good thing to do, it does not necessarily lead to behaviour
change, as we have seen. Programme managers need to monitor
message content closely and ensure that it does not deviate too far
from the positive messages that were planned.
26
The size of the investigation
There are no hard and fast rules for deciding how many focus groups
or structured observations you will need to carry out. The size depends
on the size of the target area; the larger and more varied it is, the more
formative research you will need. One rule of thumb is to carry on with
the investigation until you are no longer learning anything new. We
give three imaginary cases. You can work out the approximate size of
the investigation by taking intermediate values depending on how much
your circumstances resemble the ones shown :
Case 1: A region with 800,000 people, both urban and rural, with diverse
cultural backgrounds.
Case 2: a small town of about 200,000 people with two main language
groups.
Case 3: a cluster of ten villages which are ethnically homogenous.
Case
Environmental Structured
Checklist
walk
observation observation
Focus Behaviour Structured
group
trials
interview
Region
10
localities
200
households
10
days
12
4 groups
of 10
20
Small
town
4
localities
120
households
6
days
6-8
3 groups
of 10
10
Villages
3
villages
70
households
4
days
4-6
3 groups
of 8
10
Getting the balance right
Another factor in your choice of sample size is the scale of your
proposed programme. There would be little point in spending so much
time and using up so many resources in formative research that nothing
was left for the intervention. But skimping the formative research could
lead to costly mistakes, wasted effort and demoralisation for all
concerned. What is the proper balance between the two? Spending
around 15% of programme resources on getting the programme set
up properly at the beginning is well worth while.
27
Tips for team building
The quality of the formative research depends on the motivation of the
fieldworkers to to a good job. They may have to begin work early, and
stay in remote locations; they may encounter difficult people, and they
are putting their noses into people’s private business, which can be
stressful. Good support and morale boosting is essential for the quality
of the work.
0
0
0
0
0
0
0
0
0
0
0
0
0
28
Involve the whole team in planning and decision-making and make
it clear that their contributions are valued.
Hold regular team meetings to air problems, share solutions and
hold social events to boost morale.
Choose staff with experience of extension work, who are interested
in hygiene, and who speak the local language(s).
Ensure that contracts and financial arrangements are clear,
understood and agreed by all parties from the beginning. Review
any problems promptly.
Stick a weekly planning calendar on the wall, so that everybody
knows what everybody else is doing, including team leaders.
Involve the whole team in piloting the formative research and revising
the formats and guides that you will use.
Allow a long lead-in period to train staff and pilot and develop the
formats and guides.
Harmonise approaches by pairing up staff so they can learn from
each other. Settle on an agreed introduction in households, so that
everybody explains what they are doing in the same way.
Regular, frequent supervision assures quality and punctuality.
Even one field worker who cheats can ruin the whole investigation,
so tackle any suspected problems rapidly and seriously.
Review data as it comes in from the field. Don’t make corrections in
the office, but go back to households.
If you are using a computer to enter data, check on the quality of
data entry regularly.
Hold team think-tank sessions to review findings and develop ideas
about the key questions. Early results guide the later work.
Chapter 3
Risk
Practices
The previous chapter gave an overview of the process of formative
research and how it is used to design a hygiene promotion programme.
This chapter summarises what hygiene promoters need to know about
the practices that put children at risk of diarrhoael disease.
&
31
I*'
09705
I'
Risk
Practices
Too many messages!
Look at the lists of messages below. These are all common in hygiene
education programmes. But there are so many! And they are confusing.
Two messages are normally the maximum for effective communication.
So which two would you choose?
"cover water containers”
“boil drinking water”
“filter drinking water”
“chlorinate well water"
“use a dipper for water”
“wash hands with soap”
“wash hands with ash or mud”
“do not wash hands with mud”
“wash hands before eating”
“wash hands before feeding child”
“wash hands after defaecation"
“wash hands after cleaning up
child”
"teach child to use a
potty"
"bury faeces"
"disinfect latrines and
. slabs”
“cover food"
“use fly screens for food”
“disinfect vegetables”
“reheat food"
"burn rubbish”
"bury rubbish”
“transport rubbish to a
depot”
“clean well surrounds”
"build latrines"
“cut fingernails”
“comb hair”
“do not spit”
“wear clean clothes”
The only way to make a sensible choice is to know about how people
catch diarrhoea, and to know what practices are common in your target
area. Then you can pick out the most risky practices.
32
Where do intestinal infections come from?
The origin of diarrhoea is: EXCRETA!
One grammej of faeces can contain:
I
/
10, 000, 000 viruses
1, 000, 000 bacteria
1, 000 parasite cysts
100 parasite eggs
Infectious diarrhoeas (including dysentery, cholera and typhoid) are
caused by infectious agents like viruses, bacteria and parasites. These
agents get into humans via the mouth and are passed out in faeces.
ENEMY NO 1: FAECES!
33
How do people catch diarrhoea?
Fluids
Fields
Foods
Faeces
New
Host
Flies
Fingers
This is the famous f-diagram, which shows the different routes that
the microbes of diarrhoea take from faeces, through the environment,
to a new person. For example; microbes in faeces on the ground by a
well can get into the water (fluids) and be drunk by a child, hands that
have not been washed after going to the toilet can carry microbes onto
foods, which are then eaten, infecting another child, who gets diarrhoea
and spreads more microbes...
34
How can we break the transmission chain?
Fluids
Q.
o
o
Fields
OT
2
ra
Foods
w
Faeces
New
Host
Flies
O)
.E
</)ro
5
Fingers
If we can prevent faecal material from getting into the environment in
the first place, then we do not have to worry so much about purifying
water, storing food correctly or keeping away flies. That is why our first
priorities should be:
- safe stool disposal
- handwashing with soap after stool contact
35
Risk Practices: The Evidence
There are many practices that can help prevent diarrhoeal infection. But which
are most important? We review the evidence.
Getting rid of faeces
Faeces in the public and domestic environment are the
primary source of diarrhoeal pathogens. Safe disposal
of stools is the best way to prevent infection. Ideally,
adult and child stools should be disposed of in toilets or
latrines. In places where this is not possible, stools should
be buried. As a last resort, it is better to carry stools to a
place far from play areas or water sources and cover
with earth, than to leave them lying in the yard. In places
where they are available, teaching toddlers to use potties
can help to keep the home area free of faeces.
Faeces of animals like pigs, cows and chickens can also carry diarrhoea
microbes and need to be kept out of the home and where children play.
Hand washing
Hands readily become contaminated with faecal material
after anal cleansing or after cleaning children's bottoms
and stools. Rinsing fingers with water is not enough to
remove sticky particles which contain microbes. Hands
need to be well washed after contact with faeces; either
rubbed with an abrasive such as ash or mud, or with a
detergent such as soap.
Handwashing before eating, before feeding children and before preparing
food are all helpful. But we now know that following such advice systematically
would require a woman to wash her hands with soap about 30 times a day,
which may not be practical. Most important is handwashing with soap (or
ash) after stool contact.
Keeping water clean
There is much debate about the importance of safe water.
A plentiful and accessible water supply makes hand
washing and cleaning easier, which helps to keep the
environment free of pathogens. Ensuring that faecal
material does not get into water supplies at the source
is probably far more effective than boiling, filtering, and
covering water jars. Safe stool disposal is a priority.
36
Fly control
Though flies can carry microbes from faeces to food, fly
control is difficult and expensive to achieve. If stools are
disposed of in toilets or latrines and these latrines have
covers or fly traps, then fly-based disease transmission
will be minimised. Here also safe stool disposal is
the priority.
Food hygiene
Poor food handling practices contribute to diarrhoeal
infection largely because they offer bacterial pathogens
the opportunity to multiply. This way people can consume
much greater doses of microbes. Diarrhoeas often peak
in warm, humid seasons in the tropics, when conditions
are favourable to the multiplication of bacteria on food.
r
Food stored in a warm place is an environment that microbes like, where
they can multiply easily. Feeding bottles are especially dangerous because
they are hard to sterilise and bacteria grow quickly in warm milk. Poor handling
of bottles and child food are therefore major risk factors for diarrhoeal diseases
in young children. Hence a cup and spon is preferable to a bottle, both for
infant milk and semi-solid weaning food. But the microbes that cause diarrhoea
come from stools. Preventing stools from getting into the domestic
environment in the first place is therefore a priority.
For a summary of the scientific evidence concerning hygiene risk practices
see Actions Speak (Boot & Cairncross) and Improving water and sanitation
hygiene behaviours (WHO). Apart from preventing diarrhoea, safe disposal
of stools and improved hygiene has other benefits, such as reducing infection
with intestinal worms.
To sum up, unless your field work shows you otherwise, the evidence
suggests that the most important way that microbes infect children is
by getting into the environment from faeces in the first place. Therefore
two of the most important practices for hygiene promotion programmes
to target are likely to be:
SAFE STOOL DISPOSAL
HANDWASHING WITH SOAP AFTER CONTACT WITH STOOLS
37
Chapter 4
Key Practices to Address
In the previous chapter we saw that the source of diarrhoea causing
microbes are stools and that not disposing of stools safely and not
washing hands with soap after stool contact are important sources of
risk. In this chapter we suggest how you can work with target
communities to design safer hygiene practices.
39
Target
Practices
How to identify risk practices
We know that certain hygiene practices are more risky than others,
and that those that let faecal material into the home environment are
the most risky. However, to decide which practices to target, we need
to know what people actually do. How do they dispose of child or adult
faeces? Do they wash their hands with soap after coming into contact
with faeces? What other practices are causing a problem locally?
How do we set about finding this out? Just asking is not good enough;
hygiene practices are private and are morally loaded; nobody likes to
admit to not washing their hands, for example. The first step is to
choose a number of representative communities in which to work. A
variety of techniques can then be used to collect information about
risk practices. These include:
0
0
0
40
Environmental walk
Checklist obsen/ation
Structured observation
Environmental walk
A good way to .begin the formative research is to take an environmental
walk. Choose sites that are representative of your target area, and
having made the customary contacts with leaders, administrators, etc,
ask a group of local people to show you round your chosen villages/
neighbourhoods. It is a good idea to do it at dawn or dusk as you will
see more hygiene behaviour then. Ask to see the water sources, the
places where rubbish is thrown. Chat to mothers and fathers about
their children, what their problems are, how they manage to keep their
households and their children clean. Ask about problems with sewage,
latrines, stagnant water, how they manage their babies and children,
the age children learn to defaecate alone and where, who helps with
the children and so on. Write up what you learned about hygiene
straight away after the visit. (Hygiene Evaluation Procedures, by
Almedom, describes this, and many other useful techniques.)
Checklist Observation
Make a list of all the behaviours that you
think might be putting children at risk of
diarrhoea (see the list on the next page
for ideas). Be sure to include all the
practices which might allow faecal
material into the environment. Take the
team and spend several days in one of
your target communities from early
morning ‘till night. Ask to sit with
mothers, childcarers and children and
watch what goes on. Join in with the
family life. Each time one of the
behaviours on the checklist is seen, note
when and where it happened and who
did what. Tell the family you are
interested in child health but not that you
are especially concerned with hygiene.
41
Checklist observation can be carried out in a number of sites,
depending on how big and varied your target area is (see Chapter 2).
Afterwards, sit down with your team and decide which practices seem
to be putting children at risk.
Write up your conclusions in a short report.
Sample Checklist
Note: who, how, where, when, with what?
-child/infant defaecation
-adult defaecation
-other defaecation
-anal cleansing
-child bottom cleaning
-child stool removal
-handwashing after anal cleansing
-handwashing after cleaning child's bottom
-water collection
-water handling
-handwashing before preparing food/ feeding child/
eating
-animals in the compound
General Observations:
-stools on the ground
-latrine
-living space
-other possible risk practices
42
Structured Observation
The results of the checklist observation will have given you a short list
of practices that are allowing the spead of microbes from stools into
and through the environment. Now you need to know how common
,;sk practjces are. Risky practices which are frequent are a major
c health problem; practices that are rare are probably not a priority
Dur programme.
jrving behaviour directly gives more valid results than interviews
is et al). Structured observation is a systematic technique for
rving and recording particular practices. It lets you quantify specific
;ne practices directly. It is also used to to monitor the impact of
irogramme on the target practices before, during and after an
/ention.
:tured observation is carried out by a team of trained observers,
ask permission and then visit households, often very early in the
ing as people get up. They then sit as quietly as possible in a
e where they can see what is happening. Each time they see a
ice of interest they note down what happens on a pre-coded form,
le next page is an example of a sheet taken from a structured
rvation format: you can adapt it to your needs. To fill it in, the
rver puts a ring around the number which corresponds to what
ees. This simplifies recording and data handling. You can complete
>rm with the other practices that you noted as possible risk practices
g the checklist observation. You can also add spot checks of
her stools are seen on the ground, animals in the yard, etc.
defaecation is likely to be one of the practices of interest, so
ise households with young children (say, under 3) for the
rvation. Child defaecation and stool disposal will only be seen on
t a half to two thirds of visits. This has been allowed for in the
)le sizes suggested in chapter 2.
advice from local people about the acceptability of structured
rvations and ensure that fieldworkers do not impose themselves
milies who would rather not participate.
43
15 tips for carrying out structured observation
0 Plan to cover between 70 and 200 families, depending on how big
and how varied your programme area is (Chapter 2).
0 Households should be chosen at random (from a map or household
list or, if neither exist, by taking every 4th or Sth house along a street,
for example).
I Only observe in households with small children.
I Visit families the day before and ask their permission, explain that
you are doing a study of child health or of women’s work, but not
that you are specially interested in hygiene.
I If someone doesn’t want to participate, thank them politely and try
another house.
I Preferably find female field workers who don't mind getting up very
early. (Male field workers may be less welcome observing hygiene)
I In one month, five field workers can cover 100 families.
I Observe for a standard period, say from from 06.00-09.00 each
morning.
I Test the observation formats and revise them so that they cover
every circumstance you might meet before finalising them.
I Train field workers carefully so that they all fill in the forms the same
way. Make a written list of instructions.
I Arrive at the household at getting up time, greet people and then sit
down quietly in an corner where you can see what is going on.
I Keep conversation to the absolute minimum.
I Supervisors need to visit the field workers regularly.
i Hold frequent team meetings to decide what to do about unexpected
observations and to give moral support to the team.
I Tabulate the results by hand (or use a computer)
I Decide how much you think people changed their behaviour because
of the observer, and mention this in your report.
44
A sample structured observation format
Section 2. Structured Observation of child defaecation
2.1 Did you see the child (0-3yrs) defaecate during the observation
period?
yes=1
no=2
2.2 Where did the child defaecate?
on a pot=1
on the ground in the
house=2
on the ground in the yard=3
on the ground outside the yard=4
in nappies=5
in pants/trousers=6
in the latrine=7
other=8
2.3 Did someone clean the child’s bottom after it had defaecated?
Who?
nobody=1
the child herself=2
mother=3
sister/relative=4
maid=5
other=6
not seen =7
2.4 What happened to the stools?
thrown in the latrine=1
left lying on the ground=2
thrown outside=3
taken to the rubbish heap=4
washed off=5
not seen=6
2.5 After cleaning the child's bottom/cleaning up stools did the person
wash both hands with soap=1
rinse both hands with water only=2
rinse one hand=3
Tabulate the results, either with a computer or by hand. Look at the
frequency of the risk practices that you suspect to be causing a problem
and pick out those which are common enough to be a real threat to
public health. Finally, narrow down your list to just two or three risk
practices.
45
Developing
Community
Target
Practices
with
the
Up till this stage, you have mainly been learning from your sample
communities; the time has now come for more active collaboration.
You have now identified two or three types of practice which you think
are the main causes of child diarrhoea. They will probably include unsafe
disposal of child and/or adult stools, lack of handwashing with soap
after stool contact and other high risk behaviours which are specific to
the locality. You now need help from the communities to develop
replacement practices.
Behaviour trials
Behaviour trials are a new technique which enable health workers and
representative members of the community to work together to design
replacement practices for those that are putting people at risk. You can
also use them to find out about behavioural motivation by asking what
people like and dislike about the new practices (explained in Chapter 5).
Step 1. Set up the trial. Find a number of women who aren’t using your
target safe practices. (You can use the results of the structured
observations to identify possible candidates). Invite three or four groups
of about ten to local meetings. Make sure that they are roughly
representative of your primary target audience. At the meeting discuss
the results of the observations and your analysis of practices that are
putting children at risk. Ask for their suggestions as to what could be
done. Ask for volunteers to work with you to try out safer behaviours.
Offer physical support such as soap, so the trial does not require them to
spend money. If, for example, you noted that children defaecating on the
ground was a common risk behaviour, then you might explore whether
using banana leaves or potties was feasible and acceptable to mothers
in your area.
Step 2. Home visits. Fieldworkers visit each volunteer at home and work
with her to adapt the target practices to her individual circumstances.
They ask her to do her best to carry them out for two weeks.
46
Step 3. Follow-up. Visit each volunteer each day at first (every two
days in the second week) to support her, to remind her and to find out
how she is getting on. Work with her to solve problems and find
alternatives. If she has no latrine for example, can she use a neighbour’s
or bury child stools, for example? After several weeks most mothers
will have developed workable replacement practices. You will, at the
same time, gather some lessons which will be useful when it comes to
scaling up the intervention. Key questions to ask at each visit are:
Did you manage to adopt the new practice?
What difficulties did you have?
How did you solve the problems?
What else could we do to make it easier?
Did you like the new practice? Why? Why not?
What were the costs (time/money)?
What were the benefits?
Keep track of the results at each visit by filling in forms like the one
shown below.
Behaviour trials: sample follow-up form
Day No/date
Family ID No |.
Carer
Child
1
2
3
Problems
Solutions
Advantages of new
practices
Where did they last
defaecate?
1= latrine in the yard
2= neighbour's latrine
3= in a potty
4=on the ground
5=other (note)
How were hands washed
after stool contact?
1 = not washed
2= plain water
3= with soap
4= other (note)
47
Step 4. At the end of the trial, summarise
-the exact sequence of events that go to make up the target practices
-the problems encountered,
-the solutions found by the participants,
-the advantages that participants felt that they got from the new
practices.
Meet with the women again to check what you found and feed back
the results. Finally write up a statement showing the risk practices and
the target practices like the examples shown below.
Risk practices
13% of mothers wash their
hands with soap after cleaning
up a child’s bottom.
20% of child stools are left on
the ground.
Target practices
30% of mothers use soap to
wash their hands immediately
after cleaning a child's bottom
and throwing away the stools.
40% of child stools are thrown
in a latrine or buried.
48
If
Making the links
In some places it will not be possible to find the ideal solution to problem
practices. Soap or water may be unavailable for handwashing, or there
may be no latrines for the disposal of stools, for example. When this
happens, two types of solution are needed, one immediate, one long
term. For the long term, better infrastructure is required. The formative
research may highlight this need and recommend the building of water
or sanitary infrastructure, or suggest modifications to an existing
programme. Community ownership of the results of the formative
reaseach can help galvanise further political and community action for
better resources.
Nevertheless, the formative research should still be able to find interim
solutions that allow better hygiene in homes in the absence of improved
infrastructure. For example, it is rare for there to be no soap at all.
Most houses keep soap, or a soap equivalent, for washing clothes.
Earth or ash can replace soap, and can be promoted if people find this
acceptable. If latrines are not available in the short term, the solution
may be burying, or ensuring that stools are disposed of well away from
households. The priority is to reduce the faecal contamination of the
environment in which children live.
49
Chapter 5
Motivating
Behaviour Change
You have read about behaviours that need to change to protect
children's health. However, behaviour change is never easy and
conventional health education doesn’t work. In this chapter we show
51
(13705
Motivating Behavior Change
A new way of thinking about behaviour change
In the previous chapter we saw how to identify the practices that were
putting children at risk of diarrhoeal infection. We saw that the unsafe
disposal of child stools, and failure to wash hands with soap (or ash)
after coming into contact with stools, are probably the main practices
which allow microbes into the environment of the vulnerable child. We
also saw how to work with communities in the target area to develop
replacement practices which are feasible, affordable and attractive.
But this is only a part of the solution. We saw in Chapter 1 that teaching
people about microbes and diarrhoea is impractical on a large scale,
and not very effective in encouraging behaviour change. So what is
the alternative?
Hygiene promotion uses a different approach. Instead of being topdown, it starts by finding out what the community likes about the target
practices. It then uses these positive values to motivate behaviour
change. So if, for example, we find that dignity and respect from
neighbours are seen as the main benefits of adopting the target
practices, then these values are used in their promotion.
To find out about the perceived advantages of the new practices, the
first step is to discuss them with groups of women (Focus group
discussions, p56). The next step is to interview women who are already
using the safe practices, to find out why (structured interviews, p 60).
Finally, a number of women can be asked to try out the new practices
as we suggested in the previous chapter. These women can then
52
From smelly yards to happy husbands:
an example
A health worker wanted to find out about how to motivate people to
dispose of child stools safely. This is what she did:
The health worker and her team carried out four focus
group discussions to ask about the disposal of child
stools. Mothers explained that they did not like to see stools
\
on the ground because they were ugly to look at and “they
\
S'°P y°u breathing". They said that they admired mothers
who managed to keep their courtyards free of stools. But
they said that it was hard to always keep an eye on the
child so as to be able to clean up afterwards.
The team interviewed some mothers who managed to keep their yards
stool free. “My mother-in-law gave me a potty for the child” said one
woman, “I taught the child to use it so now the yard isn’t smelly anymore".
The team asked for volunteers to participate in behaviour trials. Each
mother was given a potty, and asked to teach the child to use it. After two
weeks they were asked what they thought. Mothers said that it had been
difficult at first but that the child got used to using the pot after about
three days. Others said
that the potty was convenient, others
that their husbands had noticed that
the yard was cleaner and free of
smells. They all agreed that even if a
plastic potty cost a bit, it was well
worth buying one for the sake of living
in a nice clean healthy environment.
The health worker decided to build
her hygiene promotion strategy
around the idea that a happy,
healthy family use potties to have
a smell-free yard.
53
Everybody wants to be clean!
Mothers in Bobo-Dioulasso were asked what they thought about
stool-related hygiene. Here are some of the things they said:
“There’s a bad smell [from stools on the ground] which disturbs us and
if a visitor comes to see you are ashamed that they see and smell the
stools. You can’t even eat nearby because it smells so bad."
“Stools outside, they bother you, they judge a mother by that."
“Stools on the ground cause problems with the neighbours, we are
...insulted."
“I’ve noticed that when I use soap I don’t have smelly hands any more,
that’s good, especially when I go to pray."
“I like soap because it gets rid of bad smells...”
“Stools on the ground bother people. They walk in them. The
motorbikes get dirty and have to be washed. Not to mention the
smell..."
“Washing hands is a good thing because it helps avoid illness. I do it
because I’m convinced. What illnesses? Like coughs and malaria.”
“Our husbands like the yard clean”
As you can see, mothers offered many reasons why hygiene is
important to them. Nobody likes dirt, nobody likes to have stools lying
around, or to have hands that smell bad! As this example shows, we
would be wrong to think that the basic motivation for hygienic behaviour
is health. More important are the desire for comfort, beauty, and social
acceptability. A basic ideas of hygiene promotion is the use of people's
existing values to promote safer practices. This is because a better
quality of life, self respect and respect from neighbours, convenience
and cost saving are stronger motives than disease avoidance.
This is a positive way of promoting hygiene, and much more effective
than trying to frighten people that their children will get diarrhoea if
they don't mend their dirty habits. In any case, most people don’t think
Name
Symptoms
Causes
Kolobo
Green, frothy, frequent
stools, vomiting, weight
loss
Teething
Kotigue
Liquid stools, ballooned Anal fissures due to
stomach
carrying the child on
the back or sitting in
____________________ the damp_________
Sere
Bad smelling stools
Thin, complaining child
Breast feeding whilst
pregnant/after having
sexual relations
Fariguan (fever)
Liquid, smelly, stools
Mother has fever
Siin coumouni (sour
breast milk)
Toubabou konoboli
(white’s diarrhoea)
White, milk smelling
Mother’s milk gone
stools
sour in the breast
Liquid stools, ballooned Dirty food
stomach
55
Finding Out What Motivates Behaviour Change
The question we need to answer in our formative research is: what
motivates the adoption of safe hygiene practices? It would be hard
to find answers in ordinary household interviews. Instead we use:
i
i
focus group discussions
interviews with safe practitioners
behaviour trials
The number of each you need to carry out depends of the size and
homogeneity of your target area (see Chapter 2).
Focus group discussions
Focus groups are an excellent way of getting to the bottom of a subject,
especially about why people do or think what they do. They gather
together people with similar backgrounds for a detailed discussion about
a subject. In the hands of a skilled moderator they can produce
remarkable results. (However, if the moderator does not know how to
put people at their ease, or she accepts only superficial answers and
does not dig into what people really think, then they are less useful.)
The technique is now widely used in health research and there are a
number of helpful guides to using this technique, such as that by
Dawnson. We summarise how to go about it here.
The key things that you need to carry out a focus group discussion
are:
i
I
clear objectives
a well thought-out discussion guide
a moderator who makes participants feel comfortable
a determination to find out what people really know and think.
1/ Beforehand
Decide on the objectives of your FGD.
Make a first draft of your discussion guide. Get the team mem
ber who knows the community best to propose how to phrase
the questions. Improve and revise the guide together.
Choose a location that is convenient for your participants where
you won't be disturbed too much.
Invite around 6-12 people who are representative of your target
groups.
Select a group with similar backgrounds so that everyone feels
at ease to say what they think with the others and everyone feels
equally concerned.
Prepare the meeting: arrange for chairs, refreshments, writing
materials or tape recorder, batteries and cassettes if you decide
to use them.
You need at least two people to carry out the FGD; one Facilitator
and one Recorder.
57
21 During the Focus Group Discussion
Arrange the group in a circle.
Introduce yourselves, explain the reason for the meeting.
Try to put everyone at their ease.
Use the local language.
Include everyone in the discussion, don’t allow any one person
to dominate.
Don’t accept just the first answer but probe until you get to the
bottom of what really motivates hygiene
I
Notes need to be as complete as possible a record of what is
said. (Tape-recording is ideal, but transcription from tapes is time
consuming. Using notes alone can be inaccurate. One solution
is to listen to your tape once over, and then transcribe from notes.)
The discussion should last about an hour, and never longer than
two hours.
The facilitator leads the discussions, makes sure that everybody
participates, and brings people back to the subject when they deviate.
She does not dominate the conversation, but leads it gently when
Write up a full and complete transcription of what was said by
everyone.This can be done by hand or with a computer. Local
words for key concepts (diarrhoea, dirt, etc) should be retained
and not translated.
The transcript is your data. It should be carefully saved for future
reference.
Go back to your key questions. Use a highlighter pen to show
what was said in each discussion on a given subject (e.g blue
for handwashing practices). Note points of agreement and points
58
Below is a sample discussion guide which you could use to help
establish the motives for washing hands with soap after contact with
stools and disposing of stools safely. (You would obviously have to
adapt it to local conditions and to the target practices you have chosen.)
Some people find it helpful to bring along objects or pictures to get the
Focus Group Discussion Guide
Objective: to establish what might motivate handwashing with soap
and safe stool disposal.
Note: date, time, location, participants, facilitators.
1. Introduction
Introduce yourselves and the participants.
Explain what the focus group is going to discuss and why.
Explain that people are free to say what they like and that they will not be
quoted individually. Explain that notes will be taken or a recording made.
2. Perceptions about /hygiene
What sort of things are clean? Why do you say that x is clean?
What are the advantages of cleanliness?
3. Advantages of handwashingwith soap after cleaning up a child
When is handwashing a good idea? Why?
When do you need soap? When don’t you need to use soap? Why?
What do you like about handwashing with soap ?
4. Perceived advantages of stool hygiene
What about stools? Are they clean or dirty? What’s wrong with them?
What's the best way of avoiding stools?
If you throw stools in the latrine what are the advantages?
5. Adopting the target practices
Could you adopt these practices? Why? What would make it easier?
6. Closure
Summarise what was said, offer to answer any questions, promise feed
back, thank everybody, wait till everyone has left before leaving.
59
Structured interviews
Structured interviews (sometimes called semi-structured interviews)
are a means of exploring what people think about an issue without the
formality of a questionnaire. Instead they employ a discussion guide.
The interviewer probes and draws out issues of interest in a naturalistic
setting. Handled skilfully they can provide fascinating insights into what
people think. They are less useful in the hands of a fieldworker who
does not know how to make people comfortable or how to probe to get
behind the initial responses.
For good results the interviewer needs:
clear objectives
!
a good discussion guide setting out areas to probe
i
the ability to listen carefully
At this stage in the formative research, the key question is “what are
the advantages of the target practices? To answer this, you need to
find a number of child carers who already use the safe practices (the
structured observation should have identified some).Then the interviewer
tries to find out what made people adopt the safe practices, and the
benefits that they feel they get from them. If health workers are doing
the interviewing, mothers will often spend time telling them all about
health benefits. But, as we saw, health is only one, and probably not the
most important motivation for hygiene, so probe the other benefits which
child carers feel that they get from the target practices.
7 tips for the structured interviews:
I Decide on your objectives
I Make a discussion guide (see next page for a sample)
i Interview 10 to 20 women who already use the target practices.
I Raise the questions which interest you and probe for deeper
levels of motivation behind superficial answers.
I The interview should not take longer than about 45 minutes. If
you need more time, take a break or hold another session later.
I Use a tape recorder, or ask an assistant to take notes.
I Transcribe the whole interview and keep a copy safe. List out all
the motivations for the safe practices and tabulate the responses.
60
Sample structured interview guide
Objective: to find out what motivated the interviewee to adopt the target
practices, and the benefits she feels that they give her
Note: date, time, place, interviewer.
1. Introductions,
Explain the objectives and the context of the interview. Explain that her
name will not be used.Explain that we noticed that she was already
using the target practices and that we want to know how to help others
do the same.
2. Perception and experience of the hygiene practices
Does she manage to use the practices every day even if she is busy?
How long has she been doing them? What did she do before?
Who suggested them to her? How did they get her to do it?
What did other people say?
3. Advantages and benefits
What does she see as the advantages of these practices? What does
she like about them?
What about disadvantages? (eg cost, time, resources, etc).
How does she think other people could be persuaded to do the same?
4. Close
Questions, discussion, thanks.
£
I
61
Behaviour trials
Behaviour trials were introduced and described in detail in Chapter 4,
where they were used to develop target practices which were safe,
feasible and acceptable to the community. The team works with groups
of women and their families to develop the safe target practices and to
test them for a couple of weeks. The mothers who participated in the
behaviour trials will know all about the target practices and will have a
good idea of their advantages. During and after the trials you can ask
mothers about the advantages and disadvantages.
Several weeks after your trials, go back to mothers and carry out a
I
62
Motivational
Messages
You now have your data: the transcripts of focus group discussions
with child-carers, transcripts of interviews with people who were al
ready using safe practices, and the comments that people made dur
ing the behaviour trials. List out the positive benefits that people saw
or got from the new practices.
Which themes come up again and again?
i is it the pleasant smell of clean hands?
I is it the fact that the husband appreciates the clean courtyard?
I is it the fact that people felt proud to be clean when visitors came?
For behaviour to change, people have to see short term advantages
that are consistent with their long term gaols. Here is an example:
Why teach a child to use a latrine?
Shortterm advantages:
Courtyard looks nice
Get rid of bad smells
Feel comfortable with visitors
The motorbikes don’t get dirty
People don’t walk in the stools
Husband stays at home in
stead of going to the bar
Long term goals:
Live in an attractive
environment
Behave with dignity
Respect from neighbours
Keep the family healthy
Family harmony
63
Message positioning
Work together with your team to classify the short term advantages
and long term goals served by the target behaviours in your trial
communities.
Produce a positioning statement which picks out a key advantage
and a key goal for each target practice. (Positioning is a term which
comes from marketing, see Hiam, for example). It is not advisable to
position your messages around the fear of disease and the death of
children. As we saw earlier, messages about diarrhoea don’t always
make sense to people, and tend to revolt people because they are
profoundly unattractive.
Positioning statement: examples
“I want to clean up stools and throw them in
the latrine because...
...people can’t walk in them
and my neighbours will respect me.”
“I want to wash my hands with
soap after contact with stools
because...
...it leaves my hands smelling nice
and I feel good when I feel clean.”
64
Chapter 6
Communicating
Hygiene
In the last chapter we saw how to find out what people like about the
safe target practices in order to motivate people to change. In this
chapter we show how to use the results of your formative research to
design a hygiene communication programme for specific target
audiences.
67
Target
Audiences
No communication programme can expect to be successful if it does
not know with whom it is communicating. One of the tasks of formative
research is to determine who the targets of the hygiene promotion
programme should be. At this stage we should already know who is
carrying out the risk practices; they may be mothers of small children,
or school age children, or they may be other adults. But people do not
act in isolation; they are members of familiy groups and of a wider
society which has a great influence on what they do. These families or
social units are, in turn, influenced by people in authority, religious,
political and traditional leaders and agencies and institutions as shown
below. All of these groups need to be involved, or to support the
programme to ensure that it suceeds.
Community
leaders
Opinion
leaders
Religious
leaders
Donors
Neighbours
Government
. agencies
Target
Audiences
I
68
Partner
organisations S
Audience segmentation
Dividing your target audience up into separate groups to give them
different messages is called audience segmentation. The diagram gives
an example from Africa.Typically there are three groups to be adressed:
Primary audience: those who carry out the risk practices and who are
being asked to change their behaviour (inner triangle).
Secondary audience: the people in the immediate family or society of
the primary audience who support (or hinder) them in their behaviour
(middle circle).
Tertiary audience: just as important as the other groups are the
decision makers, groups, agencies and leaders who need to endorse
and support the programme if it is to be successful (outer circle).
Characteristics of target audiences
Each target audience has its own characteristics. We need to know
enough about these groups to be able to target communication
efficiently. It is no good, for example, to have an expensive television
campaign aimed at mothers if few of them watch TV regularly. However,
a TV programme to generate support from officials might be a
worthwhile investment. Such decisions can only be made if you know
certain things about your target groups. For example:
Who are the members of the target audiences?
Where can they be found?
How many are there all together?
What languages do they speak?
Who listens to the radio or watches
TV regularly?
What proportion can read?
Do they read newspapers?
What organisations and groups
do they belong to?
Which channels of communication do they like and trust?
69
Characteristics of target groups: examples
Target
Audience
Who?
Where?
Channels of
communication
Objective
Primary
Mothers,
children, child
carers
Home, markets
fields, schools
Weddings, baptisms,
lessons, home visits
street theatre, video
Change
hygiene
practices
Secondary
Fathers
mothers-inlaw, teachers
neighbours,
etc
Neighbourhood,
work places,
meeting places
bars, churches,
temples, sports
Radio, TV
meetings, press,
video projections,
leaflets, special
events
Support
the
changes
in hygiene
practices
Tertiary
Religious,
community,
political
leaders
government
partner, donor
agencies
Capital, offices
churches,
mosques,
temples
Leaflets, radio, TV,
meetings, seminars,
ceremonies,
print media,
workshops, internet
specialist press
Support the
hygiene
promotion
programme
CHANNELS OF COMMUNICATION
Channels of communication are the routes that are used to get the hygiene
message across. They include: traditional channels of information such
as word of mouth, messengers and social gatherings; modem channels
such as radio and TV, and channels which are created for hygiene
promotion, such as theatre or video shows and special events.
Channels of communication can be divided into three types:
0
0
0
One-to-one
Group
Mass
Whilst one-to-one communication between skilled communicators and
target audiences is probably the most effective way of getting a
message across, they are likely to be very time consuming and require
many staff. An intermediate solution, less effective, but less costly, is
to address groups of your target audience at meetings, video showings
or special events. Mass communication such as Radio and TV are
used more and more, and though they can reach many people at lower
cost per capita, they have a lower capacity to affect behaviour because
there is less opportunity for dialogue (Hiam).
Reach, effectiveness and cost-effectiveness
The communication programme that emerges from your formative
research needs to balance coverage and cost-effectiveness. To do this
you need to find out about how target audiences communicate, and from
this work out the reach of each potential channel. So, if for example, you
find that only 7% of targeted men read the newspapers, but 75% listen to
the radio, then radio has the better reach and would be an obvious choice
for mass media. If you find that target women do not go out much and
have little contact with any channels of communication outside their
households, then house-to-house visits will be required. Work out the
cost per capita of each form of communication and then select a mix of
communication channels which balance maximum reach and maximum
effectiveness with minimum cost (Kotler).
71
FINDING OUT ABOUT TARGET GROUPS
In this manual we describe three ways of finding out about your target
groups and how they communicate:
0
0
0
Existing information
Household survey
Focus group discussions
Using existing information
First of all, much information will already be available. You probably
already know about your tertiary target group, leaders and decision
makers, because you have worked with them before. Demographic
and survey data should be available to tell you about secondary and
primary groups. How many women of child bearing age are there in
the target area? How many school age children? What is the official
literacy rate? Contact local newspapers and ask about their circulation
figures. This is a list of some key questions to try to answer.
0
0
0
0
0
0
0
0
0
0
0
0
How many in each target group?
What is the literacy rate for each group?
What are the local organised groups? churches etc?
What are the local radio and TV stations?
What is their programme of broadcasts?
Are there any audience research figures?
What are the local and national newspapers/magazines?
What are their circulation figures?
What proportion of children are in school?
What is the school curriculum? Does it include hygiene?
How many teachers are employed?
What are the outreach activities of the health centres?
When you have collected it, make up a table which puts together all
the information that you found for each target group. You can then
use a simple household survey to find out about how your primary
(and secondary) target groups communicate.
72
Household survey
Design a survey format that suits what you know about the primary target
population. An example is shown below. It will save time and effort if you
combine the survey with one of the other activities, say straight after
completing the structured observations.You will then have a sample of
between 70 and 200 households, depending on the size of the target
area (See Chapter 2). If you decide that you also need to target men as a
part of the secondary target group you could interview them separately,
or at the same time, if it is convenient. Tabulate results in the normal way.
Extract from a household communication survey form
1. Do you have a working radio in the house?
yes=1 no=2
2. Do you listen to the radio?
every day =1, every few days=2, rarely=3, never=4
3. If you do, which radio station do you prefer?
4. If you do, what are your favourite programmes?
name
time
name
time
5. Do you belong to a local group, committee, church, etc?
6. In the last year how many meetings of this group have you
attended?
0, 1, 2, 3, 4, 5, 6,7+
8. How often has a health worker come to your house in the
last year?
0, 1, 2, 3, 4, 5, 6,7+
9. How often have you been to the clinic in the past year?
0, 1, 2, 3, 4, 5, 6,7+
10. Please read this sheet for me
read easily=1, read with difficulty=2,
not able to read=3
73
Focus Group Discussions
Having found out about how people communicate, you need to involve
your target audiences in the choice of media for the programme. The
target audiences know best which media are most appropriate for
hygiene messages. Here is an example:
An AIDS prevention programme in West
Africa used traditional messengers called
Griots to communicate the benefits of
condom use to mothers in their homes. The
programme was very successful, partly
because Griots are traditionally allowed to talk
about sensitive subjects, like sex. However,
women in focus groups explained that Griots
would not be good messengers of hygiene
promotion because they were not seen as
being ‘clean’ people. Griots were, however,
involved in composing and singing a hygiene
song at public gatherings.
A second series of focus groups may be needed to refine your
communications plan, or you may be able to ask questions about
communications in the first series of focus groups. You will need to
consider holding a few more groups for men or mothers-in-law or other
influential secondary targets of your programme. Some of the points
to cover include:
0
0
0
0
0
74
How do people get messages about local and world events?
How do the local groups and associations function?
Who are the main influences on household behaviour?
Who are the right sort of people to promote hygiene?
What, how and when is the best way to send messages?
Making a Communication Plan
You are now ready to work out a draft communication plan. Previous
chapters helped you to decide on the target practices and the
positioning of the messages. This chapter has shown you how to choose
target audiences and pick out key channels of communication.
Assemble all of the information you have, and, together with your team,
decide which channels of communication are likely to be most effective
and to be affordable within your budget.
The next step is the creative part. You need to translate these elements
into activities and events designed to get your messages over. These
are commonly called communication supports.
Communication supports
Communication supports use the senses of vision and of hearing to
convey messages.
Audio-visual supports are meant to be seen and heard; they include
theatre, video, film, and teaching with visual materials
Oral supports use words alone to pass messages, this may be in the
form of a story, a radio announcement, or a visit from a health worker.
Written supports include leaflets, posters and articles in the press
Visual supports include posters, stickers and flip charts.
According to Hiam, Kotler and Graeff the best support media:
0
0
0
0
0
0
0
are attractive: so that they pull people in
use local idiom and situations: so that people feel it concerns them
are repetitive: so that messages are retained
are easy to understand: so nobody gets confused
are participatory: an exchange of views is most effective
are provocative: so that they are memorable and discussed
show by example: so that the new practices are seen to be
possible.
75
Producing communication materials
For each channel of communication decide on:
0
the principal message
0
the target audience
0
the motivation (immediate advantage and long term goal)
0
the promoter (eg, a respected elder, an opinion leader, a
health agent)
0
the tone of the communication (e.g. if the ultimate goal of the
hygiene practice is a happy family, the tone of a radio advert
would be joyful and fun)
Give the task of designing the materials to small groups; include insiders
and outsiders, team members and community members and creative
people such as musicians, theatre writers, or artists. If you can afford
it, use the advice of a local ad agency. If you can’t, you may be able to
find local publicists, radio journalists or entertainers with good ideas.
Brainstorm lots of ideas and then work the best up into detailed
scenarios or images. Keep a close track of your messages and their
positioning: everybody has their own ideas about hygiene, creative
people and ‘experts’ like go their own way, rather than using your wellresearched insights into the target communities!
Testing communication materials
Testing is very important because you will not get the communications
materials right first time. The poster designed to show a mother washing
her hands may look to the target audience like she is taking a pill, the
radio ad you produce may be so funny that it distracts from the message.
The training materials for health workers may not stop them from reverting
to old habits of haranguing their audiences.
76
You will need to make trial versions of all of your materials and test them.
Prototype posters can be taken to a school or a health centre and people
can be asked what they see in them. Small focus groups with
representatives of target groups can be held to evaluate tapes of radio
programmes.Some members of the audience can be interviewed after
the first show of a play to see what they retained. Health workers can try
out materials and give you feedback on their usefulness.
Piloting the intervention
As with any large scale intervention, it is wise to start on a small scale,
to try out and revise all your approaches in one zone, for example.
Carry out a detailed evaluation after six months and then revise your
approaches and scale up.
77
Conclusions:
Hygiene promotion: practical and effective.
Changing household hygiene behaviour is one of the most effective
means of preventing children from acquiring diarrhoeal disease. Indeed,
the health impacts of water and sanitation interventions are mostly
mediated through improvements in hygiene. However, hygiene
education, as it is usually practiced, has had disappointing results.
Reasons for failure include: not basing efforts on what people know, do
and want; assuming that teaching about microbes will bring about
behaviour change; not targeting just a few key feasible hygiene behaviour
changes; turning off potential audiences with talk of dirt, death and
diarrhoea; not offering positive, attractive solutions and not setting
realistic and measurable behaviour change objectives.
This manual proposes a new alternative which sets about designing hygiene
promotion programmes in a rational manner. It begins with what people
know, do and want, and combines this with what experts know about
hygiene to develop effective programmes. The new approach uses
formative research to find out about and work with representatives of target
communities to develop new, safer practices which are feasible and
attractive. It then promotes these safe behaviours on the basis of the
advantages that people perceive (which may or may not include health).
Finally it investigates how people communicate and uses a mix of modern
communication strategies to reach the widest audiences most effectively
at the least cost. The formative research process is a simple and logical
means of designing a hygiene promotion programme in collaboration with
the people who need it.
1
Once the programme has been designed and the communication
strategies and materials thoroughly tested and revised, the programme
procedes in the normal way. Regular monitoring of the process of the
intervention, as well as of the behaviour change results, allows the
programme to be modified and improved over its lifetime. The techniques
described in this book adapt themselves well to the task of monitoring.
For example; focus groups are an excellent way of determining what
people are taking away from a theatre presentation or a radio play.
Questionnaire surveys can help determine the level of coverage of the
78
programme in terms of the proportion of the population having had a
home visit from a community worker, or how many have taken part in a
group discussion about hygiene, for example.
Finally, such programmes can be evaluated using structured observation
to determine how much change has occurred in target practices.
Hygiene promotion is a new approach for many institutions who are
used to working in old ways. In addition, it is hard to find people with
skills in formative research and communication. As a result hygiene
promotion teams will have to find out for themselves how to make their
work more effective.
It is hoped that this manual is sufficiently clear to be used as a do-ityourself guide to more effective hygiene promotion. Even if
circumstances do not permit the approach to be used exactly as it is set
out here, many of the elements of the approach can still be adapted to
fit existing projects and programmes. Any ways of working which can
help put what people think, want and do at the heart of programme
design has to be an advance over the health promotion programme that
is designed in an office.
LSHTM and UNICEF are keen to modify and adapt this guide to make it
of more practical use. Please send your comments and suggestions to
the director of programme division (see preface).
e\' ,
z / *■<
/
79
1
I
References
1. Almedom A et al. Hygiene Evaluation Procedures. International
Nutrition Foundation for Developing Countries. Boston, 1997.
Distributed by IT publications, London.
2. Boot M. and Cairncross S. Actions Speak: the study of hygiene
behaviour in water and sanitation projects. IRC, the Hague, 1993.
3. Burgers L, Boot M, van Wijk C. Hygiene Education in Water
Supply and Sanitation Programmes. IRC, the Hague, 1988.
3. Curtis V, Kanki B, Cousens S, et al. Dirt and diarrhoea: formative
research for hygiene promotion programmes. Health Policy and
Planning. 12 2, 1997.
4. Curtis V. et al. Structured observations of hygiene behaviour in
Burkina Faso: validity, variability and utility. Bulletin of WHO 71 1 2332, 1993.
5. Dawnson et al. The Focus Groups Manual. UNDP/World Bank/WHO.
Boston 1993.
6. Graeff, Elder and Booth. Communication for health and behaviour
change Jossey-Bass, San Francisco. 1993.
7. Hiam. Marketing for Dummies. IDG Books Worldwide. Foster City
CA. 1997.
8. Kanki et al. Des Croyances aux comportements: Diarrhees et
pratiques d’hygiene au Burkina Faso. Cahiers Sante 1994 4 359-66.
9. Kotler and Roberto. Social Marketing: Stragies for Changing Public
Behaviour. The Free Press, New York 1989.
10. Kroger A. Health interview surveys in developing countries: a
review of methods and results. International Journal of Epidemiology
12 4 465-481, 1983.
80
11. Loevinsohn BR Health education interventions in developing
countries: a methodological review of published articles.
\nternational Journal of Epidemiology 19 4 788-794, 1990.
12. Nations M and Montez L. Tm not dog no”: cries of resistance
against a cholera control programme in North-East Brazil. Social
Science and Medicine 43 6 1007-1024, 1996.
13.Van Wijk and Murre. Motivating better Hygiene Behaviour.
Importance for Public Health, Mechanisms of change. IRC/UNICEF.
1992.
14. WHO. Improving water and sanitation hygiene behaviours for the
reduction of diarrhoeal disease. Report of an informal consultation.
WHO/CWS/90.7 Geneva, World Health Organisation, 1993
81
GLOSSARY
Audience Segmentation: Dividing up the population into groups by
age, sex, position in the family, etc so as to use different messages
and communications strategies for each group.
Formative research: a strategic research process which combines
what insiders and outsiders know, do and want so as to develop
appropriate interventions
Positioning: the way in which a message is pitched to appeal to the
factors that motivate behaviour change
Reach: the proportion of a particular target audience who can be
contacted via a particular channel of communication
Risk practices: those few behaviours that are particularly putting
health at risk
Target audience: the people who carry out or influence the
practices that you want to change
Target practices: the safe practices which replace those that are
putting people at risk of disease
82
Water,
n
□
□
□
□
□
□
Environment and Sanitation Technical
Guidelines Series
Towards Better Programming
Implementing Water, Environment and Sanitation Strategies: An Overview**
Water, Environment and Sanitation Technical Guidelines Senes No 1
Towards Better Programming
A Water Handbook**
Water, Environment and Sanitation Technical Guidelines Series No 2
(ID No UNICEF/PD/WES/99-1)
Towards Better Programming
A Sanitation Handbook*
Water, Environment and Sanitation Technical Guidelines Series No 3
(ID No UNICEF/PD/WES/98-3) Reprint
Towards Better Programming
A Handbook on Mainstreaming Gender in Water, Environment and Sanitation
Programming**
Water, Environment and Sanitation Technical Guidelines Series No 4
Towards Better Programming
A Handbook on School Sanitation and Hygiene
Water, Environment and Sanitation Technical Guidelines Series No 5
(ID No UNICEF/PD/WES/98-5)
Towards Better Programming
A Manual on Hygiene Promotion
Water, Environment and Sanitation Technical Guidelines Series No 6
(ID No UNICEF/PD/WES/99-2)
Towards Better Programming
A Manual on Communication in WES**
Water, Environment and Sanitation Technical Guidelines Series No 7
* This joint UNICEF/USAID/EHP manual was first published in April 1997 under the title
“Better sanitation programming: a UNICEF handbook (EHP Applied Study No 5)”.
Publication upcoming.
- Media
9705.pdf
Position: 1842 (5 views)