Integrating Hygiene Behavior Change with Child Health


Integrating WASH and Community Nutrition Programs

(Image: counseling card on hygiene practices used in Uganda)

Improving nutritional status for young children will not happen if improved dietary intake is not combined with improved water, sanitation and hygiene practices to protect against diarrhea and other diseases. In numerous countries, we have helped develop and implement community nutrition programs with the purpose of placing vital preventive health measures in the community, including Water, Sanitation and Hygiene (WASH). Since developing AIN (Integrated Care of the Child) in 1985 with the government of Honduras, and supporting its expansion to about 15 countries in Latin America, Asia and Africa, we have made WASH part of the integrated training, counseling, and community action programming in programs focusing on improving young child nutritional status. Evaluations in Honduras and Uganda, for example have demonstrated that this combined approach can make a difference in the healthy growth of young children.

Timor-Leste: WASH formative research to improve child health

For the USAID-funded child health project in Timor-Leste, jointly managed by BASICS and IMMUNIZATIONbasics, The Manoff Group provided technical assistance on formative research on key aspects of child health and nutrition, including environmental health. We used a "community consultation"approach, which included focus group discussions, in-depth interviews, and trials of improved practices (TIPs). Findings/results included the following:

  • Hand washing: Although most people claimed to wash their hands with soap, there was little evidence that this practice was widely or consistently practiced.
  • Sanitation: Most people had and used traditional (unimproved) latrines. Children were allowed to defecate anywhere, then typically the mother would call the dog to clean up the feces. In behavioral trials (TIPs), families made and used potties (a bucket or other container with ashes) for their young children; they were very pleased with this and intended to continue the practice.
  • Point-of-use water treatment: Most people boiled their water for drinking and cooking, but water storage and retrieval were often unsafe.
  • Sitting fire: Mothers and newborns traditionally “sit fire” for one to three months, staying at home next to a hot fire to protect mother and child, in their vulnerable state, from cold air or bad winds. In TIPs with women in late pregnancy, many agreed to try new practices such as sitting further from the fire, building a smaller fire, or wearing more protective clothing as an alternative to the “protective” heat of the fire.

WASH and C-IMCI in the Democratic Republic of Congo

Through EHP II, the Manoff Group provided assistance to the USAID project, SANRU III, to integrate Water, Sanitation and Hygiene (WASH) into their Community Integrated Management of Childhood Diseases (C-IMCI) framework.  The Manoff Group provided technical assistance and training to Congolese SANRU staff and partners to:

  • Conduct formative research, which they conducted together

  • Develop a behavior change strategy based on the research results
  • Craft messages, materials, and program activities based on the research, and pre-test the materials

Some materials were designed for audiences of caregivers of children younger than five years old; other materials were tailored to health center personnel.  Some messages, based on local needs discovered during research, differed from standard WASH messages, e.g., for caretakers  of young children: “Store drinking water out of the reach of children.”  And for health center personnel: “Store sufficient drinking water and water for washing.”

South Africa: Formative Research on Reducing Child Exposure to Indoor Air Pollution

Indoor air pollution is linked to Acute Lower Respiratory Infection (ALRI) in children less than five years of age and accounts for a significant proportion of death and illness in developing countries. A team from the Medical Research Council (MRC) of South Africa with support from the USAID-funded CHANGE project (the Manoff Group was a key partner) used formative research to identify behaviors that could reduce indoor air pollution. The "identification" phase of the research found that two of the most commonly used interventions—changing to less polluting fuels or repairing or replacing stoves—were not economically feasible for these mostly low-income families.

The "trials" phase used the TIPs methodology, a formative research method that involves asking families to try selected behaviors and identify the factors that helped them maintain the positive behaviors or the barriers to practicing them. The results of the trials showed that two of the four behaviors tested—reducing the amount of time young children spent close to a cooking fire and reducing the burning time of solid fuel—were feasible for most of the families that tried them. Most of these families said they were willing to continue practicing these behaviors in the future because they had noticed improvements in their child's health and/or that their house was cleaner. This two-phase process of screening and evaluating behaviors was effective to learn what to recommend to reduce indoor air pollution.
To learn more, see:
Phase I Study: The Identification of Behavioural Intervention Opportunities to Reduce Child Exposure to Indoor Air Pollution in Rural South Africa

Phase II Study: Testing Behaviors To Reduce Child Exposure To Indoor Air Pollution In Rural South Africa

Nicaragua and Peru: Promoting Hygiene Behavior Change Within C-IMCI

In collaboration with the Environmental Health Project and the Pan American Health Organization, The Manoff Group worked to promote key hygiene behaviors within the programmatic framework of the Community Integrated Management of Childhood Illness (C-IMCI) strategy. In each country, partner organizations formed technical teams to carry out: training, formative research, strategy testing, development of communication materials and monitoring and evaluation. The projects were implemented in five communities in Peru and three communities in Nicaragua and were selected by the ministries of health and local partners. All the communities suffered from a high incidence of diarrheal disease, yet had a relatively good infrastructure of latrines and piped water. Plan International, an NGO, was active in all 8 communities. In the communities in Peru, there were 298 children under the age of five; in Nicaragua, there were 292.

After one year of behavior-change counseling with families, evaluations were carried out. In the initial appraisal in Peru, 22% of the 108 children under five in the sample had reported diarrhea in the previous two weeks. When the midterm survey was applied one year later to 114 children, reports of diarrhea fell to 9%, a significant change in diarrhea prevalence. In Nicaragua, a diarrhea-causing virus was circulating at the time of the follow-up survey and skewed the overall results, causing a higher reported diarrhea incidence among under twos. However, there was almost no reported diarrhea among three year olds and none in four or five year olds. The local health facilities reported virtually no diarrhea cases in the months prior to the survey. (Photo: shariing soap outside a latrine.)

Significant improvements were also documented in both countries for:

  • Storing drinking water in a covered container
  • Safe water handling
  • Handwashing after using the latrine
The evaluation also found:
  • Regular home visits to negotiate and monitor improved behavior
  • Reminder materials posted in and around most homes
  • Motivated volunteer promoters who became confident effective counselors
  • Widespread community appreciation of the promoters
  • Increased community organization

Peru: Creating community stores to assist behavior change

At the onset of the project, the EHP Peru activity carried out formative research, which identified significant material barriers to the adoption of key hygiene behaviors. In many cases, essential hygiene supplies were not sold in the community or were too expensive for most families. In response to these challenges, we established a revolving hygiene fund for each community to purchase supplies in bulk quantities and sell to families at or near cost. (One exception was the covered water tank with a spigot, an expensive product deemed an “essential” by the hygiene promoters. This was offered at a 50% discount to families with young children.)

The essential hygiene supplies that families and hygiene promoters selected for the community hygiene store include: Children’s plastic potties, Drinking water containers (with cover and spigot), Chlorine droppers, Chlorine, Hand soap, Detergent, Hand towels, Plastic pitchers( for handwashing in homes without piped water), Wastepaper baskets (with swinging cover), Toilet paper, Broom/ dust pan, Measuring cup for chlorine.

Within the community, each health promoter took responsibility for publicizing the availability of the low-cost hygiene products to the families he or she visits regularly. Promoters also presented the products at community assemblies, the health post, and during health fairs. Eighty-eight percent of families interviewed during the midterm survey reported making at least one purchase at their community store, indicating that a high percentage of families know about the store’s existence and are motivated to make purchases.


Dominican Republic: Mobilizing Communities for Hygiene Behavior Change

As part of the USAID reconstruction effort after Hurricane Georges, a behavior change component was added to ongoing water and sanitation improvement activities. Sixteen NGOs involved in the reconstruction effort participated in an Environmental Health Project training course led by The Manoff Group that included behavior change theory and methodology as well as field application. Following the training, a core team was created to carry out formative research related to hygiene behavior change.

This work culminated in the development, field-testing and implementation of a community-based hygiene behavior change strategy in nine rural communities in the municipality of Hato Mayor. These nine communities were just beginning water and sanitation pilot projects using the Total Community Participation (TCP) model, which focuses on mobilizing community involvement to achieve sustainability for rural water and sanitation programs. Trained Community Hygiene Promoters (CHPs) implemented the hygiene intervention using didactic materials that were developed as part of the formative research component of the overall project.

To monitor progress related to hygiene behavior change, a pre-intervention baseline survey was done followed by a mid-term survey. The surveys were part of the TCP process and the mid-term results reinforced the work of the CHPs by quantifying decreased diarrhea prevalence and improved hygiene behavior (safe water storage, handwashing, latrine use, etc.) Participatory monitoring helped empower local implementing NGOs and was essential in creating a sense of ownership, maintaining stakeholder buy-in and helping efforts to scale up the program nationally.

Participatory Monitoring of Hygiene Behavior Change: Dominican Republic (2003)