A systems strengthening approach to improve hygiene behaviours

5 min read
Image: WaterAid/Mani Karmacharya

For people to enjoy the full effects of improved access to clean water requires work to enable them to keep up improved hygiene behaviours. Om Prasad Gautam and Hannah Crichton-Smith explain how hygiene and behaviour change are central to all WaterAid’s system strengthening work.

Finding that repeating messages focused on germs and the health benefits of good hygiene practices wasn’t working, WaterAid left behind knowledge-based, educational hygiene approaches. Instead, we have embraced behaviour-centred design approaches and integrate hygiene behaviour change into ongoing government-led interventions for sustainable outcomes.

Understanding and adapting

In this approach, we listen to communities to understand their universal behavioural determinants – their drivers, motives and ambitions. We then work with creative teams to design specific innovative and engaging approaches that tap into these drivers and motives to engender lasting positive hygiene behaviour change. 

We focus on changing multiple key hygiene behaviours, such as: handwashing with soap at critical moments; safe and hygienic management/disposal of human excreta; safe domestic water management from source to the point of consumption; food hygiene, and menstrual hygiene and its management in communities, schools, healthcare facilities and policy settings. 

Crucially, we support governments to increase their capacity in executing, prioritising and allocating funding for hygiene behaviour change and sanitation interventions, and to demonstrate with evidence how much more effective modern, innovative and well-researched behaviour change campaigns can be than traditional interventions. We also work with governments to integrate hygiene behaviour change into other sectors such as health (vaccination, neonatal care), nutrition, and education, and help build (or strengthen where they already exist) monitoring and evaluation systems to assess the status of hygiene behaviours and track the impact of interventions.

The child being immunised after the hygiene session at Jahada Health Post, Nepal.
Child being vaccinated in Nepal.
Image: WaterAid/ Mani Karmacharya

Building blocks for sustainability

We consider effective coordination and integration, strategic planning and formative research, functional institutional arrangements, accountable governance, effective delivery of services and behaviour change, robust monitoring and evaluation systems, and sustained financing to be building blocks or active ingredients required for sustaining WASH services and behaviours.

  • To maximise the impact of WASH interventions, they must be coordinated and integrated into government plans and other ongoing development efforts, such as health (child health, immunisation, HIV/AIDS, maternal and neonatal health), nutrition and education. 
  • Formative research must generate evidence to inform hygiene intervention design and strategic government-led plans for all WASH interventions. Hygiene campaigns or packages should not be designed using expert opinion alone, but rather through a creative process, involving multidisciplinary teams, and built on evidence.  
  • Strong institutions with adequate capacity and resources to deliver and sustain high-quality WASH interventions and reinforce behaviours over time are essential. These institutions must be supported by policies, standards, guidelines and frameworks that set out how water, sanitation and behaviour change interventions should be implemented for sustained benefits. This is what we call institutional arrangements.
  • Service providers must be held accountable by communities and government for delivering high-quality services to recognised standards. All citizens must feel empowered to demand and utilise services responsibly. For sustained behavioural outcomes, the intended behaviour should be ingrained as social norms and both service provider and citizen should own the programme.    
  • Innovative models and approaches that ensure the ongoing effective delivery and management of water and sanitation services and hygiene behaviour change interventions are required for sustaining behaviours and service access. To change hygiene behaviours, WaterAid aims to tap into peoples’ motivations and change the surrounding environment via provision of hygiene products/facilities with visual reminders to nudge and prompt improved hygiene practice. Repeat delivery of and sufficient exposure to consistent hygiene behaviour change interventions is vital for sustained hygiene practice.  
  • A government-led monitoring mechanism is required to assess current behaviours, monitor compliance and reach of the intervention, evaluate its effectiveness and make decisions about future investment. For hygiene behaviour change, structured observations and spot checks are best, while reported knowledge, behaviour and social norms are often used as proxy indicators. 
  • Strong financial processes must ensure that financing is adequately allocated and utilised. Behaviour change interventions must be fully costed including the ongoing salaries of hygiene promotors, refresher training for hygiene promotors, behavioural products, hygiene facilities, etc. 

The ABCDE approach

To design, implement and ensure sustained behaviour change, we have developed a five-step (ABCDE) approach: 

  • Assess – determine what is known and unknown about current and desired behaviours. 
  • Build – fill in the knowledge gaps by collecting data through formative research.
  • Create – via a creative, participatory process, and using results from the formative research, design a hygiene promotion package that includes concepts, materials, tools and activities that are attractive, surprising and engaging. 
  • Deliver – execute the intervention so the target population is sufficiently exposed (at least 4–6 times within a year) to the programme’s activities. 
  • Evaluate, monitor and adapt – determine whether the predicted environmental, psychological and behavioural changes were achieved. Use lessons from the intervention to inform future hygiene behaviour change programme design and packages.

A continuous cycle of reflection, learning and adaptation to improve future initiatives underpins the ABCDE approach. Work at the local level is supported by influencing and advocacy efforts at the provincial, national and global levels to bring about transformative change required for sustained hygiene behaviour. 

Female Community Health Volunteer Laxmi Khanal conducting wheel of hygiene game during a hygiene session for mothers at Jahada Health Post, Nawalparasi, Nepal.
Female Community Health Volunteer Laxmi Khanal conducting wheel of hygiene game during a hygiene session for mothers at Jahada Health Post, Nawalparasi, Nepal.
Image: WaterAid/Mani Karmacharya

Examples of our work

Although there is no blueprint for how to bring about sustained hygiene behaviour change, two elements are central: government willingness and leadership. Without government buy-in, at multiple levels, the impact of any system strengthening efforts will likely be short-lived. 

Like many others working on systems change, WaterAid is learning by doing. Examples of how we are integrating hygiene into our system strengthening work include: the SusWASH (sustainable WASH) programme in four countries; integration of hygiene behaviour change into a routine immunisation programme in Nepal; integration of hygiene into a cholera vaccination programme in Mozambique; integration of hygiene into healthcare settings in Mali, Malawi, Ethiopia, and Rwanda; and integration of hygiene into the school curriculum in Pakistan. 

We will continue to capture and share our experience as we go, and adapt our approach and focus as necessary. 

For information on other system strengthening initiatives outside WaterAid, see the Sustainable WASH Systems Partnership and Agenda for Change

Om Prasad Gautam is Senior WASH Manager – Hygiene at WaterAid UK @omprasadgautam Hannah Crichton-Smith is Sustainable WASH Officer at WaterAid UK @hcrichtonsmith