Toolkit for Urban Water Supply Projects

Module 2

Health and Hygiene Education and Sensitisation

Table of Contents

1. The Design and Implementation of Health & Hygiene Programmes 2

1.1 HHE and WSS WSPs: Limits and Opportunities 2

1.2 Focusing upon Health Risks or upon Health Improvement? 3

1.3 HHE Interventions by WSPs 3

1.3.1 A): Assisting Existing or Planned HHE Programmes 3

1.3.2 B): Activities Initiated and Carried Out by the WSP 4

1.3.3 C): Emergency Sensitisation 4

2. Why Health and Hygiene Education is an Ongoing Activity 5

2.1 Introduction 5

2.2 Health and Hygiene Education Approaches 5

2.3 Knowledge, Attitude, Practice (KAP) 6

3. The Collection of Data and the Assessment of Needs 6

3.1 Information Needs for planning a Health Education strategy 6

3.2 Assessing the Efficiency and Impact of Existing Programmes 9

3.3 Using Collected Data 11

4. Communication for Health Education 12

4.1 Designing Health Education Messages 13

4.1.1 Introduction 14

4.1.2 Domains of Hygiene Behaviour, Messages and Timing 15

4.1.3 Standard Messages for Water Supply and Sanitation Communication 16

4.1.4 The Kiosk System and Health and Hygiene Education 17

4.1.5 Risk Assessment, Germs and Repeating the Message 17

4.2 Designing a HHE Programme: Step-by-Step 19

4.3 Health Education and the Introduction of Water Kiosks 20

4.3.1 Different Messages, Separate Activities 20

4.3.2 Health Education = Social Marketing? 21

Glossary 21

Abbreviations 21

Guide to Relevant Publications and Internet Web Sites 22

Bibliography 22

Health and Hygiene Education and Sensitisation

1. The Design and Implementation of Health & Hygiene Programmes

1.1 HHE and WSS WSPs: Limits and Opportunities

The objective of this chapter is not to present the detailed content of a health & hygiene education (HHE) programme. There a number of specialised publications available that contain detailed health education methods, techniques and messages and the way in which health and hygiene education can be “mixed” with water supply and sanitation programmes (see Bibliography and Boot 1991). Module **, Section ** of this Toolkit contains detailed information on a number of water related diseases.

The main purpose of this document and of this chapter in particular, is to assist the staff of the Water WSPs (WSPs) to ask the right questions and make the right choices, when they have to make decisions regarding a HHE strategy, target groups, messages, tools and media.

It is important to emphasise at the outset that water supply and sewerage are the core activities of WSPs. WSPs are not organisations that have the responsibility, human resources and capacity to provide health & hygiene education. In this context it is important to note that many experts consider health & hygiene education to be an ongoing effort and not an issue that can be solved by organising a few sensitisation campaigns.

However, one has to be aware of the fact that a WSP has the objective to contribute to the improvement of public health in its service area. This is done by providing a high quality product – treated water - but also by making sure that this product is used in a proper way. If a customer buys a radio, he or she will find a manual next to the product. This manual explains in some detail how the radio has to be used and maintained and what the owner can do if the product does not function properly or falls short of his or her expectations. The HHE approach of the WSP should be based on the principle that a water supply and sanitation (WSS) WSP should explain to its customers how the product that has been purchased has to be used. The HHE strategy of the WSP should, therefore, focus upon the following aspects of water supply and water consumption:

· The use of containers (the need to clean containers, preferable before arriving at the kiosks).

· Transporting water.

· Storage of water.

· Treatment of water at the household level.

· Water consumption (how to consume treated water).

· Water quality and water usage (it is not necessary to use treated water for all use purposes). The various usages of water (drinking, preparing meals, bathing, washing, construction work, etc.) and the water quality they require.

· The use of water from unprotected sources (risks and possibilities).

· The importance of keeping the water kiosk clean (what customers and others can do to contribute to a cleaner kiosk).

Some of these activities are discussed more in detail in Module ** of this Toolkit and in the documents mentioned in the bibliography of this document.

The challenge for the WSP will be to develop an adapted and effective health and hygiene approach. This is an important challenge as many residents of low income areas in Kenya are still used to consuming unsafe water. Some residents even lack the financial resources to purchase treated water.

1.2 Focusing upon Health Risks or upon Health Improvement?

A HHE campaign, which puts too much emphasis of the risk aspect, may fail to reach its objectives as people have come to accept the existing situation as well as the risks they are exposed to. In Makululu, a large informal settlement in Kabwe (Zambia’s fourth largest town), residents pointed out that experience had made them aware of the health risks but had also taught them that, with the exception of a few months during the rainy season (the cholera season), the risk of getting sick after drinking water from a well was somehow acceptable. Some Makululu residents emphasised the fact that the well they use had been dug more than 20 years ago.

Therefore, in an area like Makululu, an education/sensitisation programme should not focus upon health risks but mainly stress the solutions to the current water supply and sanitation problems the WSP is planning to offer. The campaign should point out the costs (at the household level) of curing water related diseases, as well as the opportunity costs (when a member of the household is very sick, he or she is not able to work and earn money for the household) and explain that using kiosk water can be seen as an easy way to prevent a number of water related diseases.

1.3 HHE Interventions by WSPs

The WSP is able to organise sensitisation/education campaigns, if it observes that one or more of the above-mentioned issues (see paragraph 1.1) deserve special attention. Health education is, however, not a primary task (a core activity) of a WSP. The question we have to ask is what a WSP can do to support:

· Existing or planned HHE programmes.

· Professional HHE organisations and institutions.

This requires that a WSP communicates with specialised persons (the public Health Officer) or organisations (the Ministry of Health) responsible for ongoing HHE programmes, in order to find out if and how it can contribute. During these discussions, the main objectives and limitations (human resources, knowledge) of the WSP have to be kept in mind. The following contributions can be taken into consideration:

1.3.1 A): Assisting Existing or Planned HHE Programmes

The WSP can design adapted WSS HHE programmes that can be implemented by others:

· The WSP could assist in the development and implementation of a water & sanitation-oriented HHE programme for primary and secondary schools. This programme could consist of a teaching package, posters and ideas for water and sanitation games and a water and sanitation game or competition (which could take place once a year on World Water Day).

· The WSP could assist in the design and distribution of a teaching package for to be used by the staff of local clinics and by Community Health Extension Workers (CHEWS).

· The WSP could develop and distribute a water & sanitation-oriented HHE kit consisting of posters, written messages, a manual, ideas for a HHE programme and a bibliography.

· The WSP could contribute to the training of CHEWS and other health workers or volunteers such as the water committees or neighbourhood health committees.

· The WSP could organise guided tours to the treatment works and explain visitors how water is being treated and why it is better to consume treated water and water from other safe sources.

· The WSP could assist in collecting data on population, water supply, sanitation and hygiene practices.

· The WSP can contribute to a better public health by implementing a Social Welfare Assistance Scheme (SWAS) aimed at assisting destitute persons and families.

The WSP should adopt a pro-active approach. This means that the WSP has to visit NGOs and Government Institutions (schools clinics, etc.) and ask how it could contribute, instead of waiting for others to approach the WSP. By visiting schools the WSP can also try to initiate health and hygiene education.

1.3.2 B): Activities Initiated and Carried Out by the WSP

A WSP should be able to design and implement its own health and hygiene sensitisation activities. For example, campaigns which accompany the introduction of water kiosks or of improved pit latrines. A WSP should also be able to develop and implement targeted campaigns that aim at removing a specific problem, such as the pollution (littering) of water kiosks or the use of dirty containers by kiosk customers.[1]

1.3.3 C): Emergency Sensitisation

In case of an emergency, such as the outbreak of a cholera epidemic, the WSP should be able to rapidly organise a sensitisation campaign. During emergencies the WSP should coordinate its activities and work in close collaboration with the Ministry of Health.

Water kiosks are the most widespread (and often the only) “official” structures within the low income urban areas (there are usually more kiosks than clinics or pharmacies, but usually fewer kiosks than churches). This makes them suitable for the diffusion of various kinds of information (posters, and verbally transmitted information), especially during the outbreaks of certain water-related diseases.

As most kiosks are busy places, the WSP and the Operators should try by all means to prevent the kiosks from becoming a disease transmission point. On the contrary, during public health emergencies water kiosks should serve as small centres where residents can:

· Fetch clean water.

· Obtain information on how to prevent, for instance, cholera

· Purchase WaterGuard.

2. Why Health and Hygiene Education is an Ongoing Activity

2.1 Introduction

In low income urban areas HHE should be an ongoing activity. Why ongoing?

· Low income urban areas are often characterised by high levels of population growth caused by in-migration and natural growth. This means that every year new residents arrive who have to be sensitised, preferably by other residents or by Water Kiosk Operators, but if necessary by a specialised HHE team.

· Sensitisation campaigns with a relatively short duration often turn out to be ineffective in the longer run. Experience shows that many people only change their behaviour if a message is repeated over a longer period of time.[2]

2.2 Health and Hygiene Education Approaches

When designing a sensitisation message, one can adopt various approaches or even a mix of approaches:

· A source-to-mouth approach. The message focuses upon the whole chain of activities and locations (the water kiosk, the use of clean containers, transporting water, storing water, treating water at the household, drinking water, etc.).

· A health risks approach (The emphasis is on the risks involved in, for example, consuming untreated water, or not washing hands after using a pit latrine).

· A mixed approach (For every part of the chain, health risks are identified and solutions offered).

2.3 Knowledge, Attitude, Practice (KAP)

A HHE programme could also make a distinction between:

· Individual behaviour that may have an impact upon public health. For example, polluting the water kiosk and using it as a public toilet, may increase the risk of foot infections and even the possibility of an outbreak of water-related diseases. The emphasis should be on kiosk cleanliness and hygiene and related norms of proper conduct and social behaviour as well as on the responsibilities of the Operator and the SWSC.

· Individual behaviour that can have a negative impact upon the health situation within the household. For example, the use of dirty containers for transporting and storing water can make household members ill. The use of WaterGuard and/or boiling water that is used for drinking or preparing meals, is likely to have a positive impact upon the health of the family.

· Personal hygiene. The importance of washing hands after using the toilet, etc, etc.

A HHE programme should also distinguish between:

· Knowledge.

· Attitude.

· Practice.

In other words, residents of a low income urban area may be aware (they have the knowledge) of the importance of hand washing after using the toilet, but their attitude towards hygiene may prevent them from actually washing their hands after a call. Even if residents have the knowledge and the right attitude they may not build a latrine simply because they lack the financial resources.

3. The Collection of Data and the Assessment of Needs

3.1 Information Needs for planning a Health Education strategy

According to Boot and Cairncross (see Bibliography) the: