Interventions to promote improved hygiene and sanitation
Based on the identification of barriers as outlined in Section 10.2, you can then plan appropriate interventions that aim to change people’s behaviour and practices. You learned about the four main approaches which are used to address such barriers in Study Session 9. A health promotion intervention or initiative is one that actively encourages positive behaviour, and is usually concerned with change that will occur over a relatively long period of time.
What are the four approaches to influencing behaviour that you learned about in Study Session 9?
The four approaches are individual behaviour change communication, social change communication, social mobilisation and advocacy.
A health promotion intervention would use these approaches for different purposes. Here are some examples of the aims they might be used to achieve:
- Behaviour change communication aims to promote child-friendly pit latrines in households, water treatment at the point of use, handwashing with soap, proper household water treatment, safe storage and disposal of waste water and food hygiene.
- Social change communication aims to increase community involvement in selecting appropriate design options for water and sanitation facilities, to change cultural beliefs and to promote community-led total sanitation (CLTS). You will learn more about CLTS in Section 10.4.
- Social mobilisation aims to bring stakeholders together to promote social marketing strategies in water and sanitation, handwashing, utilisation of locally available materials for construction of sanitation and hygiene facilities, technologies suitable for environments that have unstable and/or rocky soil and to introduce low-cost handwashing technologies near latrines.
- Advocacy aims to persuade decision makers to reduce the cost of clean water provision, to promote child, girl and disability friendly WASH services in schools, to improve maintenance of water points and to improve municipal waste collection services.
Now read Case Study 10.1 on open defecation and answer the question that follows.
Case Study 10.1 Open defecation
There are some communities in Ethiopia where people do not use a latrine even when one is available. This is because their tradition prohibits male and female members in the same household from using the same place to expel their faeces. It is culturally unacceptable for them to defecate on top of each other’s excrement. In particular the community considers the act of defecating on faeces of the household head or that of respectful community members as quite despicable. For example, children are not allowed to defecate on top of their parents faeces, and a wife would never defecate on top of her husband's faeces. This belief and practice has adversely affected the community's use of latrines and aggravated the widespread practice of open defecation.
Identify the type of barrier which best explains the issue raised in Case Study 10.1. Explain which of the following types of barrier it represents and why.
- Socio-cultural barrier
The barrier is related to culture and tradition so it is a socio-cultural barrier (b).
Which type of communication intervention do you think would be the most appropriate for overcoming such a barrier and why?
- Behaviour change communication
- Social change communication
- Social mobilisation
To address socio-cultural barriers, social change communication (b) would be most appropriate because the behaviour change which is needed relates to social customs.
Community-led total sanitation (CLTS)
Community-led total sanitation (CLTS) was mentioned in Study Session 9. It is a method for mobilising communities to completely eliminate open defecation by triggering collective behaviour change (UNICEF, 2008). In Ethiopia the name has been modified and you are more likely to come across ‘CLTSH’, which stands for community-led total sanitation and hygiene.
CLTS/CLTSH depends on raising awareness that everyone in the community is at risk of exposure to disease even if only a few people continue to defecate in the open. It has been successful in ensuring that all households gain access to safe sanitation facilities in many parts of Ethiopia. It helps communities to understand the negative effects of poor sanitation and empowers them to collectively find solutions to their sanitation situation. CLTSH is about bringing sustainable behavioural change. In general, it works best in villages that have enthusiastic leadership but it is also dependent on convincing everyone to change their behaviour. Besides leadership, many other local social, physical and institutional conditions affect the prospects for CLTSH.
CLTSH involves trained facilitators working with communities as they go through three phases of the process: pre-triggering, triggering and post-triggering phases (Kar and Chambers, 2008).
CLTSH pre-triggering phase
The facilitators must visit the selected kebele or kebeles prior to the community triggering. This visit is mainly to estimate the size of the community and its population but also to identify the dirtiest areas in the vicinity that are most frequently used for open defecation. This must be done with the community, possibly using a participatory mapping process, as shown in Figure 10.10. They also decide on the most appropriate season and place to conduct the community triggering.
CLTSH triggering phase
Community triggering happens at a gathering of the local inhabitants who come together to have a dialogue about concerns related to open defecation. The purpose of this dialogue is to bring collective action against the open defecation behaviour. Triggering refers to the moment when the whole community shares a sense of disgust and shame about open defecation. The facilitator helps them to come to the realisation that they quite literally will be eating one another’s shit if open defecation continues.
In particular, the aim of the triggering phase is to reach agreement about actions to be taken. The actions will be governed by bylaws developed by the community. The final output of triggering is a community-based action plan, which includes an agreed schedule and set of activities that everyone in the community commits to participating in. This involves construction of latrines with handwashing facilities and commitment from everyone that they will use the new facilities at all times.
CLTSH post-triggering phase
After the community-based action plan is prepared, the community members must put the plan into action. They develop bylaws to ensure the elimination of the practice of open defecation in their community. The plan also states who will implement and enforce the bylaw.
In this phase, participatory review meetings should be organised by community members and facilitated by Health Extension Workers or other CLTSH-trained facilitators. The main purpose of these sessions is to review the progress made towards achieving the objectives of the plan. A sanitation map prepared during triggering can be used again to follow the progress made (Figure 10.10). Households that have constructed and started using a latrine are marked on the sanitation map. Comparing this with the original map can show the progress made in the reduction of open defecation sites.