Hygiene promotion through immunisation

Under the leadership of the Government of Nepal's Ministry of Health and Population, we are embedding hygiene promotion into the national routine immunisation programme – and revolutionising the way the hygiene and public health sectors work together.

In Nepal, a new parent or caregiver will take their baby to a health centre for immunisation at least five to seven times in the first fifteen months of the child's life. This provides an excellent opportunity for health workers, including female community health volunteers, to promote good hygiene behaviours.  

Since June 2020, around 650,000 parents have received hygiene intervention multiple times every year.  

Good hygiene practices are essential to a healthy life, but changing people’s habits – and finding ways to reach people with hygiene interventions, especially in remote communities – can be challenging. But we know that it is possible by combining motivational intervention packages with immunisation.

We also know that people are more likely to change their habits for good if they are exposed to hygiene interventions multiple times. By making repeat contact with parents and caregivers during a short period, we are ensuring people make lasting changes to their hygiene habits that will improve the health of their children and families. 

We conducted a scoping study followed by formative research and a creative process to design a hygiene intervention package. From February 2016 to June 2017, we implemented a pilot programme in four districts – Bardiya, Jajarkot, Myagdi and Nawalparasi – targeting 35,000 mothers and guardians.  

The pilot was timed in advance of the Government of Nepal preparing to roll out the vaccination scheme for rotavirus – a virus thought to cause one third of diarrhoeal diseases. Improving hygiene behaviours along with the vaccine can reduce intestinal infections and diarrhoeal diseases, helping to ensure it is effective and positively impacts the health of communities.  

The pilot project aimed to:

• Integrate hygiene promotion into the national routine vaccination programme
• Strengthen Nepal’s routine immunisation system, by improving immunisation coverage, people’s trust in immunisation services and key hygiene behaviours
• Address the feasibility and effectiveness of this approach, and demonstrate best practice for scaling up the model across Nepal.

After one year, the pilot improved all key hygiene behaviours (from 2% to 53%) among the target population. It also increased immunisation coverage, reducing drop-out and vaccine wastage rate, and targeting hard-to-reach groups. Health workers and female community health volunteers improved their skills in running innovative hygiene promotion programmes also increased, and, although not measured in a controlled trial, the prevalence of diarrhoea dropped from 15% to 5%. 

Following the success of the pilot, the Government of Nepal continued to implement the programme in the four districts. During this transition phase, we provided ongoing support, including:  

• Reproducing the hygiene behaviour change intervention package for FCHVs
• Providing takeaway materials to reinforce behaviours  
• Supervising and monitoring the programme  
• Documenting learning.

Between 2017 and 2019, the programme reached about 35,000 guardians each year.

In December 2018, the Ministry of Health and Population decided to integrate hygiene promotion into routine immunisation programmes nationwide, with the aim of reaching 650,000 guardians through 27,000 local health workers.

To prepare for nationwide implementation, we provided technical support to the government to:

• Conduct a baseline assessment of indicators related to key hygiene behaviours and immunisation coverage
• Re-activate the creative process to review the programme and make it suitable for national use
• Re-shape the package to reduce the length of sessions from 45  to 30 minutes
• Deliver a master training-of-trainers session on hygiene promotion, with 31 participants from the Family Welfare Division, the Provincial Health Directorate, WaterAid Nepal and partners working in the child health and water, sanitation and hygiene sector
• Deliver 10 provincial training-of-trainers sessions across seven provinces, to 398 provincial-level trainers from 77 district health offices
• Train 27,000 health workers across Nepal to understand the hygiene promotion package and implement it independently  
• Produce and distribute about 15,000 hygiene promotional packages across 77 districts, which included 14 different hygiene promotional materials, a ‘how-to’ guide and materials to reinforce positive behaviours.

In July 2020, the Minister for Health and Population launched the nationwide programme, coinciding with the introduction of the rotavirus vaccine into the national immunisation programme. The project also included preventive hygiene behaviours to reduce the spread of COVID-19. 

Watch the video below to see how the immunisation programme contributed to Nepal’s COVID-19 response through the promotion of good hygiene practices, including handwashing. 

With our technical support, the Government of Nepal continues to review this hygiene intervention programme and deliver refresher training sessions to health workers to help deliver it.  

Since 2022-2023, Nepal’s Family Welfare Division has reported on the number of hygiene sessions, and the number of attendees, happening across the country as part of its routine immunisation programme. During 2023-2024, almost 91% of the hygiene sessions were conducted through the national routine immunisation programme. 

To sustain the initiative and improve behaviours, it is essential to continue to upskill health workers through refresher training, provide a supply of promotional materials for health workers and visual cues/nudges for households. And this all must be supported by ongoing technical support, sufficient budget from the government and the continuous involvement of health workers.  

Learnings from this project will be used to improve the outcomes of the programme and feed into wider maternal health programmes in Nepal.

Top image: Ashakala Rai, senior auxiliary nurse and midwife leads a hygiene behaviour change session with mothers and babies in Kathmandu District, Nepal, June 2024.