Putting health care workers at the heart of hygiene behaviour change

5 min read
Women in the post-natal ward at Mangamba Health Centre having given birth that morning (Sep 30th, 2018). The facilities here have changed, thanks to the UK aid match project, Deliver Life. The labour ward now has running water, a toilet and shower. Wa ...
Image: WaterAid/ Lis Parham

How do you engage communities – and the health care workers at the hearts of them – in changing hygiene behaviours? Programme Officer Abigail Nyaka describes WaterAid Malawi’s journey to create a clean campaign.

Hygiene behaviour lies at the core of any successful public health intervention. But changing social attitudes and consciousness around health and hygiene takes time, and is a major challenge in improving public health. Theoretical models and practical frameworks, such as the ABCDE model WaterAid uses, can be vital in encouraging the necessary shifts.

At WaterAid Malawi’s flagship project, Deliver Life – made possible by UK aid from the British people – we have used the model to develop a 'clean campaign' – a package to promote health through interactive hygiene behaviour change materials.

The brand

With a tag line that is also a call to action ('tiziyamba ndife', meaning 'it should start with us'), the campaign aims to inspire all to safeguard others through good hygiene practices. Given the high rates of hospital-acquired infections in Malawi, the campaign primarily targets health care workers, with the general community as the secondary target.

The campaign has two phases:

  1. to address social norms;
  2. to promote specific behaviours.

The first phase focused on branding the campaign. We created a logo, theme song, manual toolkits and visual cues as behaviour reminders.

Olive Matchado, Ward Attendant at Nayuchi Health Centre in Machinga, Malawi.
Olive Matchado, Ward Attendant at Nayuchi Health Centre in Machinga, Malawi.
Image: WaterAid/ Dennis Lupenga

The second phase centred around increasing the skills of health care workers and community members like Olive (pictured above) to practice, sustain and pass on good hygiene practices. This focused on:

  • handwashing with soap
  • using latrines properly and keeping them clean
  • safe treatment and storage of water
  • food hygiene, and
  • safe health care waste management.

To aid learning we designed activities including manuals (translated into Chichewa language) to guide community discussions, clinic appointments and health care worker meetings, and created radio shows, sports and games.

Who are our partners?

The Deliver Life project is implemented in three districts by our partners AMREF Health Africa, Evangelical Lutheran Development Service (ELDS), National Initiative for Civic Education (NICE) and district local government – Water, Health and Nutrition as well as Agriculture departments.

The Ministry of Health’s Preventive Health Services and Quality Management directorates were instrumental in pretesting with communities and helped us to connect with other communication initiatives in the country to avoid duplication of efforts. We ensured they led the process, so they can easily take over the project and make it last.

What have we achieved so far?

It was important to create the package on the basis of evidence, so we conducted formative research that helped to generate rich insights for the creative team into the behaviours we needed to target.

Through training of trainers and district-based volunteer training sessions, we built the capacity of district-level Government and implementing partners to roll out the campaign.

Launched by the Minister of Health and Population, Atupele Muluzi, the campaign has two themes: 'Hygiene promotion health worker champion' and 'Banja la ukhondo Banja la chitsanzo' ('health family, happy family'). This launch was aligned with activities around Global Handwashing Day, and we were able to talk about the campaign at the National Practitioners Symposium.

To attract further public attention we also invited popular comedians MacArthur Matukuta, Tame Mwawa, Stanley Kadzuwa and Maureen Jumaina to perform during the launch.

Three jingles were developed to help promote good hygiene behaviours to communities, which community radio station Nkhotakota has played across ten districts in the central region. At the end of each radio magazine was a quiz question for listeners to respond to by SMS, so we could assess listenership and whether people were taking in the messages. The responses were overwhelming. There was also a live broadcast during which listeners called to ask the panellists questions.

We engaged gospel musician Jeremiah Chikhwaza, who composed a theme song 'Banja la Chitsanzo' ('Model family') promoting the benefits of the five hygiene behaviors. Approved by Ministry of Health, the song is being played on radio stations alongside the jingles. Other media outlets, including social media, will be used to publicise the song and make the messages reach as many people as possible.

In the first two years of implementation, the Deliver Life project has delivered WASH infrastructure in 10 health care centres; and has reached 12,544 people with water and 20,407 with sanitation. As of 25 February 2019 (the day of our Global Symposium on Hygiene) the clean campaign had reached 123,905 people with hygiene messages and actions.

Key lessons

Designing attractive packages requires an open mind and passion. We learned that new initiatives and their corresponding innovations take time to get off the ground, so it is vital to give enough time for initial processes. On the other hand, adapting existing materials to fit the campaign brought a surprising yet familiar touch to the messages.

It is essential to ensure health facility staff 'buy in' to the campaign. They can increase communities’ ownership through their high credibility and trusted position in communities, and by promoting hygiene behaviour change in existing health talks.

The huge workload and long working hours of health care workers in low-income settings continues to reduce the extent to which they practice good hygiene behaviours, even when they are aware and willing.

Where do we go from here?

The Deliver Life project ends this month (March 2019), but we have ensured that the campaign is incorporated within traditional systems, such as health care worker meetings, client sessions at static clinics targeting outpatients departments, under-five growth monitoring clinics and community discussions.

We will continue to engage and train more district-based mentors, to ensure the campaign’s sustainability.

Together with our partners, we will regularly monitor alignment of campaign activities with deliverables and potential outcomes, through monthly meetings with community volunteers. In addition to self-reporting and in-situ observation, implementing partners and officials from the district-level Ministry of Health will collect data on behaviour through spot-checks.

We envision that our campaign will break the walls that prevent action on hygiene among health care workers and patients, and build the bridges and pathways needed to attain healthy lives through practicing good hygiene behaviours.

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