Hygiene Promotion Campaigning in Rural Settings

Systematic and participatory planning approaches are needed to implement effective hygiene promotion campaigns for refugees and Internally Displaced People (IDPs) and their host communities (THE SPHERE PROJECT 2011, UNHCR 2015a). They promote positive behavioural change around household, food and personal hygiene and can facilitate meeting the Sphere Project Minimum Standards (UNHCR 2015a, THE SPHERE PROJECT 2011, GWC 2009). Careful planning, execution, monitoring and evaluation of hygiene promotion campaigns ensures that the affected populations have the knowledge, resources, willingness and practice to prevent WASH-related disease transmission of concern in Rural Settings (HARVEY 2015, WHO AND WEDC 2013).

The Challenge for Promoting Hygiene in Rural Settings

In rural areas, the infrastructure is often weak, which makes hygiene promotion particularly important to reduce risks of hygiene-related and waterborne diseases (UNHCR 2015a). Here, risky hygiene practices such as open defecation are more common than in other settings (e.g. Camps or urban areas) (UNICEF 2012a). Additionally, there are often large disparities in the level of WASH services across rural areas and access to them is often limited. This makes it difficult to consistently meet minimum standards for hygiene and makes the logistic of doing so challenging (e.g. ensuring soap and refuse receptacles are available, UNICEF 2012a, UNICEF 2012b).

On the other hand, rural settings often have direct access to local markets, which means that hygiene items can be made available to the affected population through local businesses, hence allowing them to take ownership for maintaining good hygiene. In this case, humanitarian actors must ensure that the affected communities are provided with the financial means (e.g. multipurpose grants, cash grants) to pay for their hygiene items and water, as the IDPs and refugees may otherwise be forced to ration their water use and hygiene items (UNHCR 2012b).

Coordination and Collaboration

The primary goal of WASH interventions in rural settings is to provide access to national hygiene-related services (such as health services, nutrition planning strategies and policies, programs for hygiene promotion, etc.) and to improve services if necessary (THE SPHERE PROJECT 2011, UNICEF 2012b, UNHCR 2015a). To provide access, it is vital that humanitarian actors, local stakeholders and service providers collaborate from the start and plan the campaign in a way that local stakeholders can take over with time to ensure sustainability of the campaign (UNHCR 2015a).

In rural settings, the use of electronic mass media for hygiene promotion is often not very effective, since large parts of the population may not have access to televisions, radios or smartphones. Thus, posters and interactive methods such as home visits or group discussions are often more appropriate to disseminate and communication strategies (WHO AND WEDC 2013) (see Creating Information Material (DC) factsheet).

Schools can be another useful avenue for hygiene promotion in rural areas, since children can be very effective in disseminating information to their families (see CHAST approach). Teachers should, if possible, be integrated into hygiene promotion training programs (UNICEF 2014, see Recruiting and Training of Hygiene Promotion Facilitators factsheet).

If possible, hygiene promotion should apply an interactive approach, using methodologies such as drama, group discussions, songs, street theatre, or dance. In addition, WASH personnel should conduct house visits to make sure that any obstacles (such as language issues) are tackled to enable good communication. These communication methods can be adopted in public places such as markets, schools, distribution centres, worship places, water collection points or surroundings of sanitation facilities (HARVEY ET AL 2002). For any communication method selected, an assessment of the cultural norms of the refugee/IDP population and host communities must be carried out.

Communication and Participation

Having communities participate in hygiene promotion will allow humanitarian actors to gain a good understanding of how the public health can best be protected. Community mobilisation can then be used to empower communities to take ownership over maintaining good hygiene practices. Programmes for promoting hygiene awareness should be participatory, focused and specific, but not alarmist (WHO 2002). In rural areas, where ties of kinship are stronger than in urban areas, community leaders can have a strong influence on the community. They should thus be involved in hygiene promotion whenever possible (WHO 2002). Smaller neighbourhoods or groups that are geographically close to one another can be jointly mobilised to promote hygiene. This is a particularly appropriate strategy for populations dispersed over large areas and difficult for humanitarian actors to reach and conduct intensive hygiene promotion campaigns (HARVEY 2015).

Hygiene Committee or Health Clubs

If possible, WASH programs should have hygiene committees or health clubs developed and run in cooperation with the refugee and IDP population and the host community (UNHCR 2015a). All programs should have a gender-balanced and representative committee responsible for promoting hygiene and implementing hygiene promotion campaigns. In rural settings, Community-Led Total Sanitation and Participatory Hygiene and Sanitation Transformation (PHAST) are good approaches to community mobilisation (UNICEF 2012b).

Mobilising the community for hygiene promotion is best done in a phased approach that is adapted to the level of development of rural areas and to the stage of the emergency/humanitarian crisis (HARVEY AND CONOLI 2015). In the immediate emergency phase, hygiene promotion should focus on (HARVEY AND CONOLI 2015):

• Ensuring necessary resources are provided to the refugee/IDP population to carry out proper hygiene.
• Ensuring that the refugee/IDP population has the basic knowledge to prevent disease.
• Mobilising the community to act to address WASH-related problems.
• Mobilising the community to act concerning the design, use, management of WASH services.

In the medium- to long-term post-emergency phase, hygiene promotion should follow an approach more in line with development settings, involving continuous assessment, analysis, design, implementation, monitoring and evaluation of risks (a concept commonly referred to as Linking Relief, Rehabilitation and Development LRRD) (HARVEY 2015).

Defining the Campaign Strategy

A strategy needs to be put in place that justifies ‘‘WHY hygiene promotion is important in the specific context, HOW the key hygiene risk practices have been identified, WHO are the priority at-risk groups and WHY, WHAT are the most effective hygiene promotion approaches and activities and WHY, HOW the target activities for each at-risk group will carry out and HOW the effectiveness of the plan will be monitored’’ (HARVEY 2015). The following components should be addressed by the strategy and prioritised according to the risk assessment: community and individual action, use and maintenance of facilities, selection and distribution of hygiene items, monitoring, community participation and communication with WASH stakeholders (see graph below).

Planning and Preparation

When planning a campaign, a team which is responsible for planning and executing the hygiene promotion campaign needs to be rapidly set up (WHO 2015). The assessment and preparation steps for developing a hygiene promotion campaign should be applied according to the following steps (adapted from GWC 2009, UNHCR 2015a, and HARVEY 2015):

Step 1: Assessment (see also factsheet on WASH Needs Assessment)

• Identify key risk practices and get an idea of the level of knowledge, the practices and level of understanding of WASH.
• Participatory approaches such as Participatory Rural Appraisals and problem tree analysis may allow members of the refugee and IDP community as well as the rural host community to analyse the situation related to hygiene and make their own decisions.
• Determine which practices allow for diarrhoeal microbes or diseases transmission.
• Identify the practices that are the most harmful to human health.

Step 2: Consultation

• As soon as possible, consult men, women and children on hygiene needs and items to include in hygiene kits.Seek to form a close liaison with the host community.
• It is necessary to separately assess the needs of refugee and IDP population residing with host families and those refugees congregating in public areas or land (HARVEY and COLONI 2015).

Step 3: Initial planning through definition of goals and objectives

• Define the aim of the entire campaign based on unique needs that were revealed in the needs assessment (see WASH Needs Assessment factsheet).
• Set one or two purpose objectives referring to the wider objectives of the campaign and targeting specific hygiene practices. Select these based on which practices have the greatest potential impact on public health and which are achievable. Also, consider what can be done to enable change of risk practices.
• Determine two to four outputs that should be achieved.
• Select measurable indicators and means of verification for each objective (such as those in Sphere Project Hygiene Promotion).
• Identify potential areas for intervention (e.g. on the hardware side such as water systems or hygiene items, or on the software side such as education or advocacy).
• Set out action plans for achieving the objectives.

Step 4: Planning through identifying target audiences and stakeholders

• Decide on which segments of the refugee/IDP population will be targeted by the campaign, based on an assessment of risky hygiene practices;
• Determine important stakeholders who influence the people that employ these risky practices (teacher, community leaders, etc.).

Step 5: Planning communication campaigns and modes of intervention

• Decide on initial key messages (such as WHO`s Facts for Life).
• Key messages should be provided early and should be in local languages and should consider levels of literacy. Keep in mind that literacy may vary largely in rural settings.
• Messages should target risk practices and not be communicated along with too many other messages.
• Posters and interactive methods such as home visits are often most appropriate as is the use of electronic mass media is often not very effective in rural settings (WHO AND WEDC 2013).
• Define the initial mode of intervention for media campaigns (see Media Campaigns - Radio (DC) and Creating Information Material (DC) factsheets) as well as for other means that the target audiences trust (women`s discussion groups, traditional healer). Also, define locations where to best reach target groups (consider gender).
• Determine advocacy and training needs for stakeholders (see Recruiting and Training of Hygiene Promotion Facilitators factsheet).

Step 6: Recruitment, identification and training of workers and outreach system

• Base recruitment and training on the capacities (systems, skills and approaches) that already exist among the active humanitarian actors (See Recruiting and Training of Hygiene Promotion Facilitators factsheet). In a rural setting, this should also include strengthening local capacities (e.g. municipal authorities and municipal and local services).

Implementation and Continued Assessment (see also Project Implementation factsheet)

• Implement the defined actions (e.g. distribution of hygiene kits or carrying out media campaigns).
• Hold meetings/ interviews with key informants and stakeholders to initiate an interactive approach.
• Conduct ongoing assessments to understand the motivation factors behind positive behavioural change around hygiene.
• Obtain quantitative data and carry out a systematic data collection in a participatory manner and in coordination with other sectors.

Monitoring (see also Participatory Monitoring and Evaluation factsheet)

• Monitor the hygiene promotion activities (e.g. distribution of hygiene kits, installation of toilets) and people’s level of satisfaction.
• Monitor and evaluate hygiene promotion campaigns against hygiene-related indicators on safe access to quality sanitation and on satisfactory living conditions (UNHCR 2015b). The relevant indicators for rural settings (referred to in standard as “out of camp setting”) include:
  •  ≥ 90% of households have soap present in the house (which can be presented within 1 minute),
  •  ≥ 60% (emergency stage)/ 80% (post emergency stage) of households can name 3 of the 5 circumstances in which it is critical to wash hands

Adaptation

• Refine the campaign based on the changing situation and move towards more interactive methods of communication and participation in comparison towards later emergency stages.
• Rapidly adapt the intervention and campaign based on monitoring outcomes and empower the communities to maintain their longer-term hygiene promotion structure (e.g. committees).
• Continue training and monitoring and adapt approaches as necessary.

Planning Timelines

Hygiene promotion plans should be revised every six months based on monitoring outcomes (HARVEY 2015).

Promoting the Maintenance of Good Hygiene Practices in the Long-term

To ensure that the hygiene promotion campaign promotes practices that can be sustained in the long-term, the following points should be considered (IA 2014):

• Use multiple communication methods and make use of hygiene promoters, schools, women’s groups, youth groups and mass media;
• Carry out multi-sector planning and delivery together with health, child protection, livelihoods and non-food items sectors;
• Increase participation and decision making of beneficiaries;
• Use a child-centred approach (see CHAST approach);
• Approach disease monitoring and awareness campaign in an integrated health and education manner;
• Support and strengthen WASH committees and health clubs;
• Monitor and conduct impact assessment and use the information gathered in programme planning and adapting hygiene promotion campaigns.
• Ensure systems are in place for operation and maintenance of facilities to enable maintaining good hygiene practices (see Ensuring Appropriate Operations and Maintenance Services factsheet).

The guidance is applicable to a rural setting with refugees and IDPs living in individual accommodation, within host families or on public land in rural areas.