In a ground-breaking approach to hygiene behaviour change, we’re working with the Nepalese government to promote good hygiene practices among parents and caregivers at immunisation clinics.

About the project

Together with its Ministry of Health and Population, we are embedding hygiene promotion into Nepal's 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 times in the first nine months of the child's life. This provides an excellent opportunity for health workers, including female community health volunteers (FCHVs), to promote good hygiene behaviours.

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

We also know that people are more likely to change their habits for good if they are exposed to hygiene interventions multiple times. By contacting parents and caregivers repeatedly 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.

The pilot programme

From February 2016 to June 2017, we implemented a pilot programme in four districts: Bardiya, Jajarkot, Myagdi and Nawalparasi. The project aimed to:

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

Improved hygiene practices can also improve responses to oral vaccines, including the rotavirus vaccine, by reducing intestinal infections and diarrhoeal diseases. Rotavirus is thought to cause one third of deaths linked to diarrhoea, so improving hygiene behaviours and vaccine effectiveness can have a positive impact on a community's health.

After one year, the pilot programme improved key hygiene behaviours from 2% to 53% among the target population. It also increased immunisation coverage, reducing drop-out and the vaccine wastage rate, and targeting hard-to-reach groups. The ability of health workers and FCHVs to run innovative hygiene promotion programmes also increased and, although not measured in a controlled trial, the prevalence of diarrhoea reduced from 15% to 5%.

The pilot programme was based on a behaviour-centred design approach, and a rigorous five-step process mapped its design, implementation and evaluation:

1. Assess

  • In 2012, we ran a scoping study which showed sufficient interest in Nepal for piloting and developing an appropriate hygiene promotion intervention.
  • We agreed the pilot project concept and a memorandum of understanding with the Nepal Government, Ministry of Health (MoH) and Child Health Division.
  • Together with the Child Health Division, we developed a project management structure, and supported the creation of a technical support unit with staffing under the Ministry of Health/Child Health Division.

2. Formative research

  • We conducted 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 helped us better understand the project’s target settings and focus population, and prioritise the five key hygiene behaviours for promotion: exclusive breastfeeding, food hygiene, handwashing with soap, water and milk treatment, and proper disposal of child faeces.

3. Create 

  • A creative team designed an innovative but simple, emotional, attractive and scalable hygiene behaviour change intervention package that targeted all five key hygiene behaviours.
  • The intervention package activities were designed using emotional drivers such as nurture, disgust, affiliation, status and attractions.
  • The intervention had a unique brand with a programme logo, a theme (‘clean family, happy family’), and an inspirational goal (of being an ‘ideal family’), and 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.

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 900 immunisation clinics.
  • The project aimed to reach about 35,000 new parents or caregivers 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.

5. Evaluation

  • We measured key indicators before project implementation and the success of the campaign after one year.
  • All key indicators, including key hygiene behaviours, were structurally observed, immunisation practices monitored and the capacities of FCHVs and health workers assessed.

Scaling up nationwide

Following the success of the pilot programme, the Nepalese Government continued to implement the programme in the four districts. During this period, 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; and 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 following the positive results during the pilot and transitional phases. The aim of the nationwide integration was to reach 650,000 guardians – through 27,000 health workers at local level – at the seven visits they make to immunisation clinics with their children before they are 15 months old.

To prepare for nationwide implementation, the government, with our technical support, took the following actions:

  • Re-activated the creative process to review the programme and make it suitable for national use
  • Re-shaped the package to reduce the length of sessions from 45 minutes to 30 minutes
  • Conducted a baseline assessment of key hygiene behaviours and immunisation coverage-related indicators, to understand the status before nationwide implementation
  • Delivered 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 water, saniation and hygiene sector
  • Delivered 10 provincial training-of-trainers sessions across seven provinces, to 398 provincial-level trainers from health offices of 77 districts, including active participation from health professionals
  • Produced and distributed about 15,000 hygiene promotional packages across 77 districts, which included 14 different hygiene promotional materials, to use in the hygiene sessions and to build the capacity of hygiene promoters
  • Trained 27,000 health workers across Nepal to understand the hygiene promotion package and implement it independently

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 government mobilised health workers to accomplish the roll out in 2020, with our support and that of other partners, such as USAID. 

The project team included preventive hygiene behaviours to reduce the spread of COVID-19 in the national package, given its launch after the onset of the global pandemic. See how the immunisation programme contributed to the COVID-19 response through the promotion of good hygiene practices, including handwashing.