Hygiene and Sanitation:

What are you going to do about

it? And where do you start?
Janet S. Ausel, PE
WASH Advisor

With many thanks to Pamela Crane-Hoover of Lifewater and Lael Kucera of Living
Water International for their contributions.
 The Motivation

In 2012, over 1 Billion people

practiced open defecation
(14% of the world population or 1 in 7 people)

Do you think they wash their hands?

 Why Hygiene and Sanitation Promotion
• Donor driven programming leans toward “clean water”
projects
• 11% of the world lacks improved water sources
• But 35% lack improved sanitation and 14% have no
sanitation facilities at all
• 1.7 million children die every year from diarrhea and
acute respiratory infections who are under five. These
figures could be cut dramatically if hand washing with
soap were widely practiced
• Statistics vary on efficacy of hygiene programming but
bottom line is clean water alone has only a fraction of
the impact compared to making headway in sanitation
and hygiene.
The F-diagram

http://www.water1st.org/millions-of-children-die-each-year/
 Selection of Methodologies

• It is now understood that ‘educating’ people about

health benefits is, in many cases, not sufficient to change
people’s behavior.
• What behaviors are you trying to change?
– Hand washing
– Sanitation
– Soap use, etc.
• How do you change peoples behavior?
– Law (threat of punishment)
– Motivations/Barriers
– Cultural Norms
 Factors Influencing Selection
External Factors Effective Internal Factors
Training
&
Communi Social-
Govern- cation
ment Cultural
Support Factors

Effective H&S Rural vs.

Programming Urban
Legal
Frame-
work
Environ-
ment

Budget Economic
and Status
Staffing
Relationship of Types of Programming
Programming Frameworks

Participatory Planning Tools

Hygiene Promotion Sanitation Promotion

 PHAST: Participatory Hygiene and
Sanitation Transformation

History:
Began in 1993, started by
Water and Sanitation
Program, World Bank and
WHO

http://www.who.int/water_
sanitation_health/hygiene/e
nvsan/phastep/en/
 PHAST: Overview

• Goal: Hygiene behavior change

• Method: Communities gain awareness of their
current WASH status using participatory activities
• Develop and carry out their own solutions
 PHAST:
Methodology
 PHAST: Strengths/Weaknesses

Strengths Weaknesses
• Rewarding for the • Requires in-depth training
communities of facilitators
• Communities gain confidence • Facilitators need to be
and responsibility for their winsome
own projects
• Relatively time intensive for
• Pictures and activities facilitate
the communities
inclusion of illiterate
community members
• Has been used since 1993 so
many resources have been
developed and are available
open-source
PHAST: A Word from the Field

Name: Vũ Hồng Hà
Organization: Samaritan’s
Purse
Country: Vietnam
Method: PHAST
 CLTS: Community Led Total Sanitation

History:
Developed by Dr. Kamal
Kar in Bangladesh, 1999

http://www.communityledtotalsanitation.org
/resource/handbook-community-led-total-
sanitation
 CLTS: Overview
Communities analyse and improve their own sanitation status through raising
awareness of the harm caused by Open Defecation (“OD”) through virtually
“eating faeces”. Single objective is for communities to become Open
Defecation Free (“ODF”)

Not dependent on external

services, or on hardware Focuses on igniting a change in
subsidies sanitation behaviour rather than
constructing toilets.

No central latrine design is

stipulated. Use of local materials is Encourages local innovation, and
greatly encouraged. Embraces stimulates local / natural
concept of “sanitation ladder”. leadership
 CLTS: Methodology
Triggering

• Transect walk
• Interactive demonstrations
• People feel disgust/shame
• Leading to a desire to change
 CLTS: Strengths/Weaknesses
Strengths
• Results in ODF communities
• Community members take
ownership and build their own
hardware without assistance
• No barrier to sustained use of
latrines (not dependent on
outside donor)
• Motivates natural leaders to
rise up
• Methodology easily
reproduced (by natural leaders
in the community)
Weaknesses
• Requires in-depth training of
facilitators
• Facilitators need to be winsome
• Doesn’t work well where there
have been subsidies in the past,
in urban centers
• Can be challenging where high
water table or unstable soils
• How do you get people to move
up the sanitation ladder?
• Unknown if it sustainable over
longer periods of time.
 CLTS: A Word from the Field

Key Points/Lessons Learned

• Work where other people
aren’t working since others
have subsidies
• Modify the method: In DRC
not a pure form of CLTS
Name: Peter Elim given the government
Organization: Tearfund structure
Country: DRC • Shaming: Government
fighting the shame aspect
Method: CLTS
 CHCs: Community Health Clubs

History:
Developed by Africa
AHEAD in 1994

http://www.africaahead.org
 CHC: Overview

• Goal: Hygiene behavior change

• Promotes a “culture of health”
• Weekly meetings open to entire community
• 23 lessons with homework
• Membership cards and graduation ceremonies
 CHC: Methodology
Stage 1: Health Promotion: ~One year for Stage 1 & 2
• Community Mobilization and CHC Formation, Base Line
Survey, Health Promotion Sessions, HIV/AIDS Prevention,
Home Hygiene improvements
Stage 2: Sanitation & Water
• Encourages self supply of water points and income
generation from water points, CHC decide everyone must
have sanitation, rubbish disposal
Stage 3: Skills training & Income generation projects
Stage 4: Civic Responsibility
• Supportive social networks for the vulnerable,
counseling/coping mechanisms, support for HIV/AIDs or
terminally ill
 CHC: Strengths/Weaknesses
Strengths
• Members of a CHC have
increased learning, raise
social status, opportunities
for income generating
activities
• Does not require literacy
• Effective at various points
on the hygiene/sanitation
ladder
Weaknesses
• Men not always active
participants
• Lengthy period of
implementation
• If community members are
paid for implementation,
not necessarily sustainable
CHCs: A Word from the Field

Name: Lydie Pierre

Organization: Living Water
International
Country: Haiti
Method: CHC
 More Methods!

• Many based on similar tools PRA tools, etc.

• Tools and materials available from sites such as
Hesperian, CAWST, UNICEF and others.
• CCG – Community Care Groups (often more a MCH
focus with specific H&S lessons included)
• Modified hygiene training in Disaster Response
 Guidelines

• Modify: Make the method, tools, timing, etc. work

for you
• Barrier Analysis: Established curriculum are great,
but you can be more effective you figure out why
people don’t do a practice
• Gospel: Hygiene training is a amazing venue for
sharing the gospel
 Children’s Hygiene and Sanitation

Proven Premise: Methodologies:

• Hygiene practices • CHAST
acquired in childhood • SLTS
• Easier to change habits • CtC
in children than adults • WASH in Schools (WinS)
• Start them early! • Many others
 CHAST: Children’s Hygiene and Sanitation
Training
• Developed in 2002
• Based on PHAST but directed toward children
ages 5-12
• Utilizes educational games and activities
• Sessions of <30 children
• Weekly sessions for 6 months
 SLTS: School Led Total Sanitation

• Developed in 2005 - Mobilizes child clubs to motivate

communities to build and utilize latrines
• Built on elements of CLTS and uses similar approach
• Children encouraged to adopt hygiene and sanitation
behaviors and become the agents of change in a
community
• Dependent on the efficacy of teachers
 CtC: Child-to-Child

• Rights-based approach to health promotion

• Educational process linking children’s learning to
actions promoting good hygiene and development of
themselves and others
• Typically components of another program, not a
hygiene curriculum, per se
 WinS: WASH in Schools

History:
Began in 1998 partnership
of IRC, UNICEF and WHO

Significantly more
emphasis on WinS in the
last few years
 WinS: Overview

• Both hardware and software components

emphasized
• Students act as community change agents
• Aims at improved and maintained facilities as well as
improved hygiene behaviors in schools and
communities
• Previously known as SSHE-School Sanitation and
Hygiene Education
 WinS: Methodology
Programming typically includes:
• Hardware:
– Adequate water supply (construction of water
point)
– Sanitation provision – toilet and urinals
– Hand washing stations
• Software:
– Administrators/Teachers: Trained to teach
students
– Community/Parents: Trained school management
committees
– Students: Active school WASH clubs
 WinS: Strengths/Weaknesses
Strengths
• Uses existing network of
schools to influence
behavior change
• Direct benefit to children,
especially girls
• Both hardware and
behavior change
• Indirect benefit to
community
Weaknesses
• Dependent on teachers who
require training and
materials
• Teachers at government
schools often transitory
and the knowledge lost
• Hardware component adds
to cost
WinS: A Word from the Field

• Name: Zerihun Hailu

• Organization: Lifewater
International
• Country: Ethiopia
• Method: WASH in
Schools
 Menstrual Hygiene
Management
• Taboo subject
• Slowly gaining recognition that it needs to be
addressed.
• Not a part of many “standard” curricula
• Include it in your programming!
– Education opportunities
– Suitable WASH facilities
– Microenterprise opportunities

(Background Photo: http://unibathlibrary.wordpress.com/2011/05/04/quiet-study-extended-during-revisionexam-weeks/)

 Menstrual Hygiene Management
• Inability to manage menstrual hygiene (including physical pain
and stress) hampers education prospects for girls and women
– 23% of girls drop out of school at menarche
– Depending on the community, 7-95% of girls skip school
during menses
• Proper understanding about menstruation and resources for
maintaining hygiene practices are lacking in many communities
– Dangerous practices
– Men know little about menstrual hygiene and typically
perpetuate the silence and neglect
• Women have less control over their bodies and resources that
help them care for themselves
– Typically lack the financial power or social status to impact
decisions that improve their health
 Educate on Menstrual Hygiene
• Implementation of menstrual
hygiene education in schools
– Educational sessions on
the biology of
menstruation
– Distribution of
informational booklets
outlining the details of
menstruation, addressing
common misconceptions,
and detailing stories from
other girls’ experiences

(Booklet Cover Photo: Abdul Gugu)

 MHM:
Resources

Feminine Hygiene Around the World. 2014. Lipgloss and a Backpack. Access from:
http://lipglossandabackpack.com/feminine-hygiene-around-the-world/
Paul S. 2014. Indian Girls Break Taboos on Menstrual Hygiene. Inter Press Service.
Access from: http://www.ipsnews.net/2014/05/indian-girls-break-taboos-
menstrual-hygiene/
Petronzio M. 2014. Half the World Menstruates. Now Let’s Talk About It. Mashable.
Accessed from: http://mashable.com/2014/05/28/menstrual-hygiene-day/
Society for Menstrual Cycle Research. Access from: http://menstruationresearch.org/
WASH United. 2014. Menstrual Hygiene Day. Access from:
http://menstrualhygieneday.org
________________________________________________________

*See bibliography of Menstrual Hygiene Matters manual. Access from:

http://www.wateraid.org/what-we-do/our-approach/research-and-publications/view-
publication?id=02309d73-8e41-4d04-b2ef-6641f6616a4f&sc_lang=en
(Background Photo: WASH United/Himanschu
 SanMark: Sanitation Marketing

• http://www.sanitationmarketing.com/resources
• http://wsp.org/toolkit/toolkit-home
Picture from: http://www.wsp.org/content/sanitation-marketing-helps-make-toilets-more-available-and-affordable
 SanMark: Overview

• Market-based approach addresses demand and supply to

increase uptake and use of improved sanitation
• Based on adapting the four Ps:
– Product: Latrine (or possibly a service like pit
emptying)
– Price: Fully commercial or certain items subsidized for
the most vulnerable
– Place: Supply chain to reach every household
– Promotion: Creating demand via promotion based on
understanding of the target audience
 SanMark: Methodology
• Assess market and partnership conditions
Plan • Plan and budget program
2-3 mo.

• Understand poor household consumers 3-6 mo.

Research • Understand businesses and supply chains

• Design affordable, desirable sanitation 5-6 mo.

Design products/service options

• Design and test supply chain and business 4-5 mo.

Test Supply models for product delivery

Test • Design and test promotional and marketing 4-5 mo.

Demand materials/tools/activities (concurrent
with supply)

• Piloting and roll out of supply expansion and 2-3 yrs.

Implement demand creation activities

Monitor • Monitor for results and equity 2-3 yrs.

 SanMark: Strengths/Weaknesses
Strengths
• Responds to changes in
demand
• Builds local capacity
• Ideally sustainable business
oriented approach
Weaknesses
• Support of businesses can
distort the market
• Lengthy implementation
time.
• Businesses not necessarily
tied to commitment to
ethical behavior
• Does it reach the most
marginalized populations?
Questions?