Hygiene Promotion (HP) is a planned, systematic approach to enable people to take action to prevent or reduce the impact of WASH related diseases. It is about making sanitation services work or work more effectively and must be supported by all involved in the response including government, local or international agencies and NGOs. No sanitation intervention should be undertaken without including hygiene promotion. HP should recognise the differences within any population and aim to respond in various ways to the different WASH needs of women and men and girls and boys of different ages from different  backgrounds, with different cultural and social norms, beliefs, religions, needs, abilities, gender identities levels of self-confidence and self-efficacy etc.

In an emergency, community structures and cohesion may have become disrupted and people will often be traumatized and grieving for the loss of loved ones. Hygiene promoters working with community members must be sensitive to this and at first may need to simply listen to people’s experiences in order to develop their trust. However, there will always be some members of the affected community who are keen to engage immediately and who can support the process of re-establishing access to sanitation and hygiene. A sanitation intervention can help to restore people’s dignity not only by ensuring access to facilities and services but also by supporting community and group organisation, engagement and decision making. Different degrees of participation (information, consultation, collaboration, or delegation of power) may be possible at different times in the emergency but there will always be space for some level of consultation.

HP uses a variety of strategies and tools to address WASH related disease risks. These can involve: advocacy, community mobilisation, interactive education and learning, behaviour change communication, participatory research, market-based approaches and people centred design.

Hygiene Promotion Principles in Relation to Improving Sanitation

A vital strategy in promoting sanitation and hygiene or increasing demand for services where there is none, is to try to understand the affected community’s different perspectives on sanitation and hygiene and to involve them in decisions about the programme.

1. Listen and ask: It is vital to learn about sanitation practices and norms. For example: What do different people usually do? What is happening now and what has changed as a result of the emergency? What do different people need and want to ensure that sanitation facilities are effective and have an impact on health? What are the priority sanitation risks? Who are most vulnerable and what support do they need to access sanitation services and facilities? Who can help e.g. affected population (who also have skills and capacities), local agencies or government departments? It is important not to treat everyone the same but to identify different groups to work with e.g. youth, mothers and fathers of young children, religious leaders, primary school children, canteen workers, hairdressers etc. See also cross-cutting chapters on inclusive and equitable design X.10 and assessment of the initial situation X.1.
2. Involve and enable action: Interactive discussions can be used to support different user groups to identify what they can do immediately to improve sanitation and hygiene. It is important to find out what is potentially stopping them from acting (the barriers and obstacles to improved sanitation and hygiene) and to find out what help they need, if any. By conducting surveys and differentiating between doers and non-doers, users and nonusers of facilities drivers can be identified that motivate action. Supporting community organisation is also useful and can help to ensure that people motivate each other. A variety of interventions can help to respond to the immediate risks but will depend on the context e.g. interim sanitation solutions, tools for digging pits, soap or alternatives for handwashing, potties or nappies for children etc. Consider how sanitation and hygiene facilities will be maintained from the beginning and the community’s involvement in this e.g. through the formation of committees or user groups.

3. Focus on vulnerability: It is vital to identify people with specific needs (e.g. women and girls, older people, and people with disabilities) and find out what they feel and need to manage their sanitation and hygiene needs (e.g. menstrual hygiene management). Ensuring that you have women on the team will mean they can talk more easily with other women. Finding out how babies and young children’s excreta is managed and asking mothers and caregivers what support they want to do this effectively, is also crucial. Work with local organisations representing vulnerable groups such as disabled people’s organisations. See also cross-cutting chapt ers on inclusive and equitable design X.10, child excreta management X.11 and assessment of the initial situation X.1.
4. Plan together: Setting practical objectives and indicators and compiling a WASH strategy with others involved in the WASH response are also key processes in an HP intervention. In this process the ‘doable’ actions that can have an impact on sanitation and hygiene should be identified and how effectiveness will be monitored should be decided. The affected community should contribute to this strategy. The recruitment, training and support of existing and new team members will help to ensure that plans come to fruition.
5. Collaborate and coordinate to implement: A variety of methods and tools can be used to work with different groups to motivate action to improve and effectively use and maintain sanitation facilities and services for women and men, people in different age groups and with different abilities. Working closely with others involved in the response – especially the Government, local authorities and other sectors is also important. Coordination involving the sharing of plans and ideas can minimise duplication and increase the efficient use of resources. It should be possible to undertake joint activities such as assessments or evaluations or HP outreach workers may focus on other priority health issues as well as hygiene.
6. Monitor and review: By means of observation (Do people use the facilities?) and surveys (Did people change their behaviour?) the effectiveness of HP and behaviour change efforts can be monitored. Continually seeking feedback from the population will enable adaptations in programming and improve effectiveness. It is also important to keep track of any rumours that might be detrimental and to respond to these as soon as possible e.g. by incorporating them into discussions with community groups or providing information on social media.

Hygiene Promotion Methods

Interactive Methods: Methods that encourage dialogue and group discussion such as ‘community mapping’ and ‘three pile sorting’ using pictures and visual representations, require the active participation of community members and are usually more effective than just ‘disseminating messages’ as the latter erroneously assumes that people will passively internalise and act upon the information provided.

Access to hygiene and sanitation items: It is important to consider the different needs of men, women, boys and girls. For example, women and adolescent girls will often need support with managing menstruation and consultation on this should be included in any sanitation programme.

WASH Behavioural Insights

In recent years, there has been a significant amount of work undertaken on trying to understand different influences on sanitation and hygiene behaviour. It is clear that knowledge about germs and the transmission of disease is often insufficient and inadequate to change behaviour. The following suggestions can help to make programmes more effective:

1. Make the practice easy and attractive: It should be ensured that products and supplies (e.g. a handwashing station with soap and water) are easily accessible in each location where the desired behaviour is expected to take place. Emphasising convenience and ease of the desired behaviour (small immediate doable actions) is often more effective at promoting behaviour change than focusing on the ‘ideal’ behaviour. Rewards and incentives such as competitions should be considered and it is useful to find ways to attract attention such as painting colourful latrine doors or handwashing facilities with mirrors.
2. Consider when people are likely to be most receptive: Disruption in context (such as that associated with most emergencies) or significant life changes such as giving birth may provide a window of opportunity for shifts in habit because people become more mindful of what they are doing. Linking the desired behaviour to an existing habit is also more likely to succeed. For example, encourage handwashing at the same time as behaviours associated with infant care such as feeding or nappy changing.
3. Draw on social norms and motivations: Psychosocial approaches to behaviour change have shown that many drivers are relevant for behaviour change and that behavior change techniques according to these drivers should be applied. To change health risk perceptions personal information on these risks should be delivered. To change attitudes, beliefs about costs and benefits of a behavior should be discussed. Appealing to people’s senses of disgust, nurturing behaviours and affiliation with a group can change emotional components of attitudes and motivate action. To change perceived norms, it is useful to convey the idea that most people perform the desired behaviour. Identify what people perceive others will think of them if they engage in the practice and try to change this perception if required. People can be encouraged to make public commitments to use toilets, wash hands or support others in building latrines with a focus on groups and communities not just on individuals. To change perceived abilities to perform a behaviour one might demonstrate the behaviour and prompt behavioural practice. To foster behaviour realisation (self-regulation) action and barrier planning is vital but also memory aids to facilitate remembering the behaviour in key situations (e.g. handwashing before touching food) are useful. Community approaches (such as Community-Led Total Sanitation and Community  Health Clubs) to the promotion of sanitation and hygiene have been found to be effective and other strategies such as  behaviour centred design and in-depth assessment of motivation are worth exploring.
4. Encourage the habit: The promotion of the habitual behavior through use of cues such as footsteps leading to the latrine and then to the handwashing facility can be considered (nudges). In addition, behavioural trials may be useful by e.g. asking people to use soap or a handwashing facility for two weeks and interview them about their experiences. Games with children can also help to internalise the link between handwashing and germs.

Common Pitfalls

Several reports, reviews and guidelines have observed a variety of pitfalls in hygiene promotion:

• Too much focus on disseminating one-way messages without listening, discussion and dialogue so that people can clarify issues and work out how to adapt changes to their specific situation.
• Too much focus on designing promotional materials such as posters and leaflets before understanding the problem properly.
• Too much focus on personal hygiene and not enough on the use, operation and maintenance of facilities.
• Too little focus on practical actions that people can adopt and how to communicate these.
• Too many behaviours and too many audiences targeted at once.
• The belief that people will always be motivated by the promise of better health in the future and failure to explore other motivations such as nurture and disgust.