In a groundbreaking approach to hygiene behaviour change, we’re working with the Government of Nepal’s Ministry of Health to reach thousands of mums and babies at immunisation clinics.

About the project

In Nepal, a new mother will take her baby to an immunisation clinic at least five times in the first nine months of the child's life. This is therefore an excellent point of contact where health workers, including female community health volunteers (FCHVs), can promote good hygiene behaviours that will improve children’s and families’ health. By embedding hygiene behaviour change in Nepal’s routine immunisation programme, we are revolutionising the way the hygiene and public health sectors work together.

Good hygiene practices are essential to a healthy life, but changing people’s habits can be difficult, and finding ways to reach them – especially in remote communities – can be challenging. But it is possible to change behaviours if we use motivational but engaging, attractive, and surprising intervention packages, and use novel approaches to implement them.

We know that people are more likely to change their behaviour for good if they are exposed to interventions multiple times. By making contact with mothers repeatedly during a short period, we are helping to ensure people make lasting changes to their hygiene habits that will improve their families’ chances of a healthy future.

The Nepal Ministry of Health and Population is leading the project, with our financial and technical support. Significantly, this approach is the first of its kind in the world. If successful, it has the potential to be rolled out not just nationally, but worldwide – helping to save thousands of children’s lives and to keep them and their families healthy.

The pilot intervention ran from February 2016 to June 2017 in four districts – Bardiya, Jajarkot, Myagdi and Nawalparasi. The project aimed to integrate hygiene promotion into the national routine vaccination programme, ahead of the introduction of the rotavirus vaccine post-2017, and to demonstrate best practice for scaling up the model across Nepal.

The project also aimed to address these key questions:

  • Is it feasible to integrate hygiene promotion into a regular service-delivery mechanism?
  • Does this approach effectively change five key hygiene behaviours of new mothers and their families?
  • Does this approach increase the effectiveness of immunisation efforts?
  • Is this approach cost-effective?
  • Is the model scalable across the whole country?

The project will strengthen Nepal’s routine immunisation system by improving immunisation coverage and people’s trust in immunisation services. Improved hygiene practices might make responses to oral vaccines more effective by reducing intestinal infections and diarrhoeal diseases. It could therefore improve the effect of the new rotavirus vaccine – rotavirus is thought to cause a third of deaths linked to diarrhoea, so improving the vaccine’s effectiveness and improving behaviours is important to the health of Nepali communities.

Improving hygiene during COVID-19

Watch the film below to meet some of the mothers learning how to prevent COVID-19 with handwashing, through the immunisation.

Preventing COVID-19 with hygiene.

Programmatic approach

We set up the project using a rigorous programmatic approach and step-wise process, so that it will achieve its aims, address key questions and demonstrate effective hygiene behaviour change programming. The design, implementation and evaluation are all based on a behaviour-centred design approach.

Five key steps map the design, implementation and evaluation of the pilot project:

Step 1: Assess

  • In 2012, we ran a scoping study which showed sufficient interest in Nepal for piloting and developing an appropriate hygiene promotion intervention. Read the findings in this briefing paper and article for the Journal of Water, Sanitation and Hygiene for Development.
  • The Government of Nepal, Ministry of Health (MoH), Child Health Division and WaterAid agreed the pilot project concept and a memorandum of understanding.
  • WaterAid and the Child Health Division developed a project management structure, with WaterAid supporting the creation of a technical support unit with staffing under the Ministry of Health/Child Health Division.

Step 2: Formative research

  • We conducted formative research to: build our understanding of the current routine immunisation system; examine the determinants of hygiene behaviours, norms and habits; and map the barriers and motives around hygiene behaviours.
  • This enabled us to better understand the project’s target settings and focus population, and to prioritise the five key hygiene behaviours: exclusive breastfeeding, food hygiene, handwashing with soap, water and milk treatment, and proper disposal of child faeces.

Step 3: Create 

  • A multidisciplinary creative group designed an innovative but simple, emotional, attractive and scalable hygiene behaviour change intervention package, through a creative process targeting all five key hygiene behaviours.
  • The intervention package activities were designed using a creative process which includes the use of emotional drivers such as nurture, disgust, affiliation, status and attractions.
  • The intervention has a unique brand, with a programme logo, a theme (‘clean family, happy family’), and an inspirational goal (of being an ‘ideal family’). The package has visual cues or nudges to reinforce behaviours in key locations.
  • The package was pre-tested and produced locally. A hygiene promotion package, made up of resources tailored to the national context, is central to the project.

Step 4: Deliver 

  • We began implementing the project in February 2016 in four districts through the Government’s routine immunisation sessions, working with 2,193 FCHVs and health staff through the 900 static immunisation clinics.
  • The project aimed to reach around 35,000 new mothers or guardians with a child aged 0–12 months at least five times through hygiene sessions, according to their child’s immunisation schedule.
  • During each session, FCHVs and health workers encourage mothers and guardians to follow the five key hygiene behaviours, using the intervention package and novel approaches.

Step 5: Evaluation

  • We measured the key indicators at baseline (established before the start of the project) and the success of the campaign after completion of the one-year project (end line).
  • To establish the baseline and compare with the end line, all key indicators, including key hygiene behaviours, were structurally observed, immunisation practices monitored and the capacities of FCHVs/health workers assessed.

The success

Our baseline and end line reports (an independent evaluation) show that the hygiene promotion intervention effectively improved all key hygiene behaviours – from 2% during baseline to 53% after one year of implementation. It also increased immunisation coverage, reducing drop-out and vaccine wastage rate and helping to target the hard-to-reach. The capacity of the health workers and FCHVs to run innovative hygiene promotion increased.

Information on diarrhoea prevalence in the intervention group was also captured. Although not measured in a controlled trial, it was observed as a secondary outcome that the prevalence of diarrhoea among the intervention group was 5% during the follow-up survey compared with 15% at baseline.

The Government of Nepal is now scaling up this approach nationwide and exploring opportunities to work with partners and donors. Evidence from this initiative will help guide how hygiene behaviour change interventions can be integrated with vaccines programmes, nationally and globally.

Scaling up

Taking the project nationwide

Moving from the pilot to scale up

The success of the initial pilot project showed that integrating hygiene into a routine vaccination programme was feasible, by effectively changing behaviours and improving immunisation coverage. The Government maintained the programme in all four districts before taking the decision to scale it up nationwide in 2019.

During this transition phase, guardians in the four districts were taking their babies to the immunisation clinic at least five times in the first year of the child’s life, for full vaccinations and to attend the hygiene sessions. We offered continuous support in this period, including reproducing the hygiene behaviour change intervention package for FCHVs; providing takeaway materials to reinforce behaviours; supervising and monitoring the ongoing programme; and documenting learning. Each year between 2017 and 2019 the intervention reached around 35,000 guardians.

Deciding to scale up nationwide

Impressed by the positive results of the intervention during pilot and transitional phase, and our continuous support, the Ministry of Health and Population decided to integrate hygiene promotion into routine immunisation programmes nationwide in December 2018, working through 27,000 health workers at local level. The aim of the nationwide hygiene integration is to reach 650,000 guardians with hygiene behaviour promotion at the seven visits they will make to immunisation clinics with their children before they are 15 months old.

To integrate hygiene into the nationwide immunisation programme, the Government, with our technical support, took the following actions:

  • Re-activation of the creative process to review the proof-of-concept package used in the pilot and retention phases and make it suitable for national use. 
  • Re-shaping of the package to reduce the length of sessions from 45 minutes to 30 minutes, finalising this slim hygiene package for nationwide use. 
  • Baseline assessment of key hygiene behaviours and immunisation coverage-related indicators, to understand the status before nationwide integration. 
  • A master training of trainers session on hygiene promotion with 31 participants from the Family Welfare Division / Child Health and Immunisation Section, Provincial Health Directorate and partners working in the child health and WASH sector.
  • Ten provincial training of trainers sessions across seven provinces, with active participation of health professionals from districts and provinces. The sessions trained 398 provincial-level trainers from health offices of 77 districts.
  • Production of around 15,000 hygiene promotional packages, distributed in the 77 districts. These include 14 different hygiene promotional materials, and are being used to build the capacity of hygiene promoters and for the hygiene sessions.
  • Training of 27,000 health workers across Nepal to understand the hygiene promotion package and implement it independently.  

Launching nationwide integration

Nationwide scale up formally began with its inauguration by the Minister for Health and Population on 2 July 2020. Integration was timed to coincide with the introduction of the rotavirus vaccine into the existing national immunisation programme. 

Because it was launched after the outbreak of the COVID-19 pandemic, we also included COVID-19 preventive hygiene behaviours in the package (see the film above). This will continue until the virus is no longer spreading in communities.

Ongoing support

The Government scaled up the intervention across Nepal and mobilised health workers to accomplish the roll out in 2020, with the continued support of WaterAid and other partners such as USAID. The Government will need continuous technical and partial financial support from partners for at least a few more years, the technical support important to both ensure programme quality and monitor its effectiveness at national scale.

To sustain the initiative and continue to improve behaviours, it will be essential to ensure capacity building of health workers through refresher training, a continuous supply of promotional materials for health workers to implement sessions, and a continuous supply of visual cues/nudges for households as part of the sessions. Continued coordination with possible donors and exploration of funding opportunities locally and internally to support this novel initiative are important.

Stories from Jajarkot

Thumbnail
WaterAid/Mani Karmacharya

Mandari

“This is my second daughter. She is four months old now. It’s very important to keep the baby clean and healthy. I do not let her play in the mud and if she touches some rubbish then I must wash her hands with soap and water. Along with this, I have to keep the utensils clean in the kitchen.

In the same way I have to keep her clothes clean and the room also has to be kept clean. I have to eat clean and hygienic food. I have to give her a bath and put her in warm, clean clothes.”

Thumbnail
WaterAid/Mani Karmacharya

Ashmita

“This is my second baby. She is nine days old. My elder daughter got all the immunisations. But immunisation is not sufficient for staying healthy. We have to maintain personal hygiene.

For my new baby, I have to change my clothes every day. The kitchen where we prepare food has to be clean. The first thing about changing our behaviour is to start within ourselves. If I want to keep my daughter clean and healthy, then I have to do it in my daily life so that my daughter can learn.”

Thumbnail
WaterAid/Mani Karmacharya

Pramila

“I wash my hands before feeding her. To stay clean and healthy I have to take bath, wash clothes and keep the surroundings clean. I also have to be careful about what she is eating and where is she playing.

I have to make sure that the food I am giving her is clean and hygienic. I have to put her in a clean place so that she will not be able to play in the rubbish and in the mud." 

Thumbnail
WaterAid/Mani Karmacharya

Swala

“I have been working as a Female Community Health Volunteer for 20 years. My main duty is to raise health awareness among children under five and pregnant women. I also advise mothers about their environment, hygiene and health.

Diseases like pneumonia, malnutrition and diarrhoea are very common in our village. I feel great serving children and pregnant women in the community. We are improving, but there are challenges as well.”