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2.8 A social marketing approach to hygiene

promotion and sanitation promotion
As we saw in Section 2.3, sanitation, along with good hygiene, acts as a
fundamental primary barrier to prevent faecal matter, the source of most
diarrhoeal pathogens, from spreading in the environment.
It is as important to enable people to change their hygiene behaviour
as it is to provide improved facilities. Practices which stop faecal
material contaminating the domestic environment are vital, especially
for children. The priorities in behaviour-change programmes are thus
likely to include hand-washing with soap after stool contact and the
safe disposal of stools (see Section 2.3.3).
According to Almedom et al. (1997),
Hand-washing with soap and water after contact with faecal
material can reduce diarrhoeal diseases by 35 per cent or more.
Using a clean pit latrine and disposing of childrens faeces in a pit
latrine can reduce diarrhoea incidence by 36 per cent or more.
This section looks at ways of encouraging safer hygiene-related
practices. It is based on a new promotional approach that draws on
social marketing, health communications, anthropology, and health
promotion. It emphasizes inclusion and builds partnership at all
levels.
Principles
The recommended approach differs from classic hygiene and
sanitation programmes because it places the consumer at the heart of
the programme. Instead of beginning in an office, programme design
begins in the community. Consultation actively involves the many
different groups in society and develops a shared agenda for action.
The process starts with data collection, to find out what target
communities need, want, and do. Appropriate interventions are then
negotiated with the health or engineering specialists and developed
into a strategic programme.
The approach works well in a participatory, village-by-village manner.
It is, however, most useful and cost-effective on a large scale, where
the intervention is first developed in a small-scale, participatory
manner, and then applied across regions or urban centres.
The promotional approach is not without contradictions. It is centred
on the users perspective, but it has a firm agenda. It uses
participatory methods but it is not wholly participatory. And there are
other contradictions to be addressed:
Faecal contamination of the environment may be the main cause of
preventable disease. This does not mean it will be the communitys
highest priority for change.
2.8
The prov|s|on o sae
san|tat|on ac|||t|es w||| on|y
|mprove peop|e's hea|th |
the san|tat|on ac|||t|es are
we|| ma|nta|ned and peop|e
have good persona|
hyg|ene.
A |atr|ne prov|des the
pr|mary barr|er aga|nst the
spread o aeca| matter.
Th|s barr|er |s eas||y
breached by a d|rty |atr|ne
or | hand wash|ng ater use
does not become norma|
pract|ce.
Promot|on o saer
pract|ces w||| best be
ach|eved by new,
promot|ona| commun|ty-
based, soc|a| market|ng
approaches that seek out
and use the messages that
w||| mot|vate change. These
must be estab||shed and
used as the start|ng po|nt to
|nsp|re behav|oura| change.
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Though improved health is the programmes main objective, the
target communities are more likely to be interested in latrines and
hygiene for reasons of dignity and aesthetics.
Messages about potential health benefits are not effective at
motivating people to change their behaviour. Attractive, positive,
messages which appeal to peoples sense of dignity are often more
effective.
It is important to consider the implications of these and other
contradictions. The agendas and priorities of development workers
often differ from those of the communities with whom they work.
This problem is not specific to the promotional approach but is
inherent in much development work.
The promotional approach aims to make scant public health resources
work effectively and sustainably over large areas, and for large
numbers of people.
We will look at the principles of social marketing and hygiene and
sanitation promotion and then turn to the nuts and bolts of
implementation.
2.8.1 Definitions
The following terms are used in this section:
Promotion seeks better health through encouraging behavioural
change. It puts consumers at the heart of programmes, ensuring
participation and partnership in programme development. The
focus of this section is on hygiene and sanitation promotion.
Social marketing uses marketing approaches to match available
resources with social needs. Social marketing may be applied to
service provision and use, the development and acceptance of
products, or the adoption of new behaviour. It can be product- or
behaviour-focused.
Consumer-orientation is fundamental to social marketing and
demands that social programmes respond to peoples perceptions
and aspirations.
Data collection is a systematic process of investigation and
collaboration with target communities to find out what they need,
do, and want, that provides information that is essential to
programme design.
Hygiene promotion encourages people to adopt safer practices in
the household to prevent sanitation-related disease.
Sanitation promotion is the marketing and promotion of
sanitation products and services.
The two key processes in hygiene and sanitation promotion relate to
the consumer. They are:
the development of messages or products that suit target audiences;
and
communicating these messages in ways that are appropriate,
attractive, and motivating.
2.8
Gett|ng the r|ght messages
depends on |rst obta|n|ng
deta||ed |normat|on o what
consumers know, do, and
want. Successu| promot|on
|s then centred on two key
processes:
deve|op|ng messages or
products that su|t target
aud|ences, and
commun|cat|ng the
messages |n ways that
are appropr|ate,
attract|ve, and mot|vat|ng.
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Hygiene promotion and sanitation promotion are both concerned with
facilitating behaviour change. Health education, social mobilization,
community participation, and central planning models have failed
more than they have succeeded. Marketing models provide an
alternative approach to behaviour change.
The promotional approach starts with the systematic use of data
collection to find out what consumers know, do, and want. The results
are used to develop concise, positive messages that address specific
health problems and to develop behaviour-change objectives that can
be monitored and measured by the project team.
2.8.2 Why hygiene and sanitation promotion programmes
need a social marketing approach
Lessons from hygiene education and sanitation programmes have
shown that:
When water and sanitation projects do not take adequate account
of individual and community behaviour the expected health
benefits are not fully realized.
In sanitation projects, goals have tended to focus on the number of
latrines constructed or the number of people given access to them.
The behaviours that determine whether new facilities bring health
benefits are rarely considered. These behaviours include hand-
washing, safe disposal of childrens excreta, personal and
household hygiene, food handling, and so on.
Hygiene and sanitation programmes have commonly been concerned
with the supply of education, and materials, rather than with
satisfying a demand from intended beneficiaries. Demand creation is
the main aim of commercial marketing. The social marketing
What can social marketing achieve?
ln Honduras, deaths due to d|arrhoea decreased a|most 50% o||ow|ng a
programme to educate mothers about the use o OPS.
Over s|x months o hyg|ene promot|on w|th a p||ot group |n Lucknow, lnd|a, the
proport|on o mothers wash|ng the|r hands w|th soap ater deecat|on went rom
under a quarter to over a ha|.
lt |s used |n |ndustr|a||zed countr|es |n programmes to prevent heart d|seases,
smok|ng, and AlDS, and to encourage the use o seat-be|ts.
ln lndones|a, 85% o women now eed the|r ch||d a m|xed ood w|th green
|eaves, wh|ch has |ead to a 40% |mprovement |n the nutr|t|ona| status o
ch||dren under two years o age.
A 30% dec||ne |n |nant morta||ty was ach|eved through the promot|on and
market|ng o OPS |n Egypt.
44% o men |n Bang|adesh d|scussed am||y p|ann|ng w|th the|r w|ves
w|th|n 12 months o campa|gn |aunch. Oontracept|ve preva|ence |ncreased by
10%.
aoao|eo /|cm Ve||a, '997
2.8
Soc|a| market|ng oers a
staged, customer-ocused
approach, convert|ng
assessed user needs |nto
demand and then prov|d|ng
the means o sat|sy|ng the
demand.
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Data to collect for a latrine programme
How many househo|ds/ne|ghbourhoods have |nadequate san|tat|on ac|||t|es
or systems?
What do peop|e perce|ve as 'good' and 'bad' san|tat|on?
What do peop|e see as the advantages o |atr|nes?
What type o system do women preer?
What type o system do men preer?
What are the character|st|cs they preer?
How much do peop|e pay and how much are they w||||ng to pay?
approach is demand led in that it uses a strategic, managed process of
assessing and responding to felt needs, creating demand and then
setting achievable and measurable goals.
Social marketing is a systematic approach to public health problems.
It goes beyond marketing. It is not motivated by profit alone but is
concerned with achieving a social objective. Social marketing is
therefore concerned with how the product is used after the sale has
been made. The aim is not simply to sell latrines, for example, but to
encourage their correct use and maintenance. The key components of
social marketing are:
systematic data collection and analysis to develop appropriate
strategies;
making products, services, or behaviours fit the felt needs of the
consumers/users;
strategic approach to promoting the products, services, or
behaviours;
methods for effective distribution so that when demand is created,
consumers know where and how to get the products, services, or
behaviours;
improving the adoption of products, services, or behaviours and
increasing the willingness of consumers/users to contribute
something in exchange; and
pricing so that the product or service is affordable.
2.8.S What happens in social marketing?
1. A sample of the intended audience, or consumers, are consulted and
questioned about their needs, wants, and aspirations. They collaborate
in the development of feasible, attractive solutions. This is Data
collection and is crucial to orienting the promotional activities (see
box below).
2. Achievable overall marketing (or promotion) objectives are
developed.
3. These data are analysed and used to develop an overall marketing
plan in collaboration with key stakeholders.
2.8
Soc|a| market|ng
programmes use data
prov|ded by the target
aud|ence to set promot|ona|
ob|ect|ves that sat|sy the
part|cu|ar demands o ||ke-
m|nded groups |n the
aud|ence. These ob|ect|ves
may be the use o
san|tat|on products, or the
awareness o san|tat|on
serv|ces.
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4. The audience is segmented into discrete units with common
characteristics. This is based on an analysis of the initial data.
5. Products and messages are developed based on consumer
preferences and characteristics for the relevant segments. These are
tested among representative samples of target populations. How much
are people willing to pay for this product? How far are people willing
to travel for this service? How feasible is the new behaviour?
Products, messages, and price are modified, refined, and re-tested
until they are acceptable. Key stakeholders are consulted throughout
this process.
6. The product is launched or service introduced.
7. The performance of the product or service is monitored and
evaluated in the market and the strategy revised accordingly. This may
involve revising the marketing plan or improving the product or
service.
The four Ps of social marketing
As in commercial marketing, the four Ps are the basic characteristics
of the social-marketing approach (see box below). A clear and well-
researched background to define each of these characteristics is
essential for the success of social marketing.
Product
Dec|de on what |s the product, |ts
orm, ormat, and presentat|on |n
terms o packag|ng and
character|st|cs
Price
Dec|de on what the consumer wou|d
be w||||ng to pay, both |n terms o
d|rect and |nd|rect costs and
percept|ons o bene|ts: make the
product worth gett|ng
PIace
Where w||| the product be ava||ab|e
to consumers, |nc|ud|ng where |t |s
d|sp|ayed or demonstrated
Promotion
How the consumers w||| know the
product ex|sts, |ts bene|ts, costs,
and where and how to get |t.
ExampIes
||co0c|s. \lP |atr|nes, SanP|ats
||ac||ce c| oe|a/|c0|. Wash hands
ater us|ng the |atr|ne
|oea. O|ean env|ronment, good
san|tat|on or hea|th
Vc|e|a|, c| o||ec|. Oost o products
(w|th or w|thout subs|d|es), soc|a| cost
Oooc||0|||,/||o||ec|. T|me |ost rom
other act|v|t|es, m|ssed opportun|t|es,
transport, |oss |n product|on or |ncome
|s,c|c|c|ca| c| o|,s|ca|. Stress |n
chang|ng behav|our, eort |nvo|ved |n
ma|nta|n|ng |atr|ne or obta|n|ng
add|t|ona| water requ|red
De||/e|, c/ o|co0c|. Tea shops,
bu||der's yards and supp||ers, c||n|cs,
pharmac|es, c|ubs, |oca| bus|nesses
De||/e|, c/ messae. Te|ev|s|on, rad|o,
newspapers, posters, b|||boards,
banners, o|k s|ngers or dramat|sts,
pub||c ra|||es, |nterpersona|/counse|||ng
The four Ps of social marketing
2.8
The bas|c character|st|cs o
the soc|a| market|ng
approach are 'the our Ps':
Product, Pr|ce, P|ace and
Promot|on.
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Target audiences ~ or who the project needs to contact
Pr|mary target aud|ences are those peop|e who are carry|ng out the r|sk
pract|ces, e.g. mothers and/or schoo|ch||dren or, or a product-based
programme, those who take the dec|s|on to purchase part|cu|ar goods.
Becondary target aud|ences are those who |n|uence the pr|mary aud|ence
and who are |n the|r |mmed|ate soc|ety, e.g. athers, mothers-|n-|aw.
There |s a th|rd target aud|ence wh|ch |s very |mportant: peop|e who |ead and
shape op|n|on, e.g. schoo|teachers, re||g|ous |eaders, po||t|ca| |eaders,
trad|t|ona| |eaders, and e|ders. These peop|e have a ma|or |n|uence on the
cred|b|||ty and hence on the success or a||ure o the programme.
2.8.4 Targeting
Targeting ~ the audiences
Programmes are more effective if a small number of key messages are
focused to specific target audiences (see box above). This
concentrates resources and increases the chances that behaviour
change will result.
The community is made up of many different groups, or segments.
Each segment of the audience may need to be addressed separately,
e.g. house-to-house visits to reach mothers, street theatre to reach
fathers, and public meetings with a video show for opinion leaders. It
is also important to ensure support for the programme from partner
and collaborating agencies; they may also be an audience to target.
Data collection is important as it provides conditions for a shared
agenda. Through the process of consultation, the best communications
strategy for each segment can be developed.
Targeting ~ the practices
Stools are the main source of diarrhoeal pathogens. Practices which
stop faecal material contaminating the domestic environment are vital,
especially for children. The priorities for public health in behaviour-
change programmes are therefore likely to include hand-washing with
soap after stool contact and the safe disposal of stools, especially
childrens stools, preferably in latrines.
Potential risk practices need to be documented and their frequencies
assessed. Practices which occur often and which allow faecal material
into the domestic environment are likely to be candidates for
behaviour change. The final target practices, to replace the risk
practices, are developed in collaboration with target audiences.
Oommunicating messages
Messages about child diarrhoea, doctors, and death are more likely to
repel target audiences than to encourage behaviour change.
Message positioning involves the selection of positive values that the
primary target audience associates with the target practices. For
example, if the data collection shows that using a latrine for stool
disposal is valued for self-respect and dignity, then the messages
should reinforce this existing positive value of hygiene.
2.8
For max|mum e|c|ency o
resource use and |mpact |n
the commun|ty, aud|ences
and unsae pract|ces must
be careu||y targeted.
Promot|on must
concentrate on the pr|mary
users and on those who
|n|uence them |n the am||y
c|rc|e or the w|der
commun|ty soc|a|
structures.
The targets or messages
on unsae pract|ces must
be those assessed as
hav|ng the greatest adverse
hea|th eects.
Messages shou|d bo|ster
those aspects o the
des|red pract|ce that users
see as advantageous. The
messages must not dwe||
on negat|ve aspects o
current pract|ces.
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The data to inform the message-positioning decision can be collected
in three ways:
1. Interview people who already use the safe practices.
2. Carry out focus group discussions.
3. Interview people after they have tried the safe practices for a few
weeks.
Communications strategies are then built around these positive values,
e.g. hand-washing with soap makes your hands smell good.
With a simple questionnaire it is possible to find out what social
groupings exist and what access people have to information, e.g.
whether people listen to the radio and when, whether people read
papers, which papers they read, who goes to the weekly market, etc.
In focus groups it is possible to identify which channels are seen as
most suitable and attractive for hygiene messages.
2.8.5 Political will
Sanitation and hygiene improvements require political will and
support. Programmes will benefit if social, cultural, and political
leaders are motivated and given an active role (mobilized) such as:
religious leaders actively supporting the campaign for sanitation; or
schoolchildren and teachers playing a leading role.
A partnership approach to promotion does not assume ignorance on
the part of the people. It is less top-down and develops, and works
from, a shared agenda. It widens ownership of the programme by
increasing the number of stakeholders who are actively involved from
the start. These additional stakeholders not only provide their
endorsement (thus widening the appeal of the initiative) but also
accept increased responsibility for implementation.
Advocacy creates partnerships with government and NGOs. It
operates on many levels: everyone from the head of state to local
government leaders should become aware of the importance of the
programme (see box on following page).
2.8.6 Programme communication
Programme communication covers identification, segmentation, and
channelling. First of all, the communication channels used by target
groups are identified. Then a mix of channels of communication is
devised to combine reach and cost-effectiveness. Specific groups/
consumers are reached through:
strategies and messages for safe sanitary and hygienic practices;
various mass media and interpersonal channels; and
improved fieldworker and supervisor training methods.
This process binds advocacy and programme communication together.
It makes the programme a priority for the society as a whole and not
just the concern of a government department, a programme manager,
or a donor.
2.8
Seek and take
opportun|t|es to en||st
|eaders rom a|| sectors and
at a|| |eve|s o soc|ety to
p|ay an act|ve part |n
promot|ona| act|v|ty.
Broaden|ng the act|ve
stakeho|der base |ncreases
the sense o consumer and
commun|ty |nvo|vement
and he|ps to spread the
message more w|de|y.
Good commun|cat|on
stems rom accurate
|dent||cat|on o the routes
best su|ted to reach
|nd|v|dua| target groups.
lntegrate a m|x o routes
|nto a promot|ona| strategy.
se as w|de a range o
commun|cat|on routes as
poss|b|e and use tra|n|ng to
|mprove a|| aspects o
promot|ona| output.
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Programme communication strategies include:
Interpersonal communication training: Strengthen the ability of
government and NGO fieldworkers to reach potential latrine
adopters and to promote sanitation and hygiene. Address
interpersonal communication skills and the quality of available
support materials.
Mass media: Build on existing policies and strengthen government
and private-sector capacity for creative presentation of
standardized messages.
Print media: Promote the development and dissemination of a
clearly defined programme logo to build awareness and aid
identification. Develop strategies using print media, e.g. billboards,
posters, site-signs, interpersonal support, and other learning
materials, manuals and programme guidelines.
Community-based media: Use local-level media, e.g. public
address systems, and employ traditional, community-based
entertainment artists, e.g. popular folk singers, dramatists, and
poets, and use their talents through the mass media.
Ring-fencing the promotional activities
Too often the promotional effort is an add-on to a project whose
budget and timetable is largely committed to hardware (water
supplies, sewage, etc.) and the promotional activities (e.g. the
software) are swamped, rushed, or curtailed. The separate projects
need to be ring-fenced but must be carefully co-ordinated to maintain
an integrated approach. (See the box on page 210.)
2.8
Strategies and agents for advocacy
Main strategies
at|ona| conerences, speeches, spec|a| events, sem|nars, |e|d v|s|ts, |etters,
d|rect|ves, news coverage, art|c|es, T\ and rad|o genera| programm|ng, and
spec|a| pub||cat|ons
Main targets-cum-agents
Med|a: press |nst|tutes, |ourna||sts' orums, T\ and rad|o
Po||t|ca|: pres|dent, pr|me m|n|ster, m|n|sters, par||amentar|ans, po||t|ca|
part|es
Adm|n|strat|ve: cab|net secretary, secretar|es, comm|ss|oners, pro|ect
d|rectors
Donors: lOEF, SAlD, JlOA, WHO, and others
GOs: GO umbre||a groups and ma|or GOs, serv|ce c|ubs, and
vo|untary soc|et|es
Po||t|ca| |eaders, op|n|on |eaders, soc|a| groups, the med|a, ce|ebr|t|es, and
donors shou|d be the ocus o advocacy. The a|m |s to turn these peop|e |nto
advocates themse|ves vo|ces who w||| take the opportun|ty to speak through
the|r own channe|s o |n|uence |n the|r own words. Advocacy must change
accord|ng to progress |n the programme.
Do not |et promot|ona|
act|v|ty become a
subs|d|ary to the '|agsh|p'
phases o a pro|ect.
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2.8.7 Hygiene promotion
Health education programmes, traditionally included as the software
part of a hardware intervention, have consistently failed to realize their
full potential to effect an improved health status. Why is this? Why do
health education programmes fail to hold any relevance to their target
audience? If the risky practices which health education identifies are
socially undesirable, why do they persist?
Hygiene promotion addresses these and other questions. Hygiene
promotion does not educate people about their risky practices but
looks at what motivates people to act, and at how hygiene behaviours are
articulated within everyday life. It builds on positive values, such as those
attributed to cleanliness, and draws on lessons from the social sciences,
e.g. anthropology, psychology, adult education, and marketing.
From health education to hygiene promotion
Four principles guided the development from a narrow education-
focused approach to a broader promotion outlook:
Table 2.8.1 Examp|es o mob|||zat|on
EIements ExampIes
Aims InvoIves Communication methods
Ga|n|ng po||t|ca| and
po||cy comm|tment
Pesource a||ocat|on
lnorm|ng and en||st|ng
co-operat|on
lnorm|ng and ga|n|ng
comm|tment
Secur|ng support
lnorm|ng and mot|vat|ng
the target groups
Advocacy
Lobby|ng
Goodw||| ambassadors
Mass med|a
Tra|n|ng programmes
Study tours
Mass med|a
Tra|n|ng
Part|c|pat|on |n p|ann|ng
Ooverage o act|v|t|es by
mass med|a
Endorsement and space |n:
Product advert|s|ng
Product |abe|||ng
Tra|n|ng programmes
Estab||shment o
commun|ty groups
Trad|t|ona| (dramas, songs),
mass med|a
PoIiticaI
mobiIization
Government
mobiIization
Community
mobiIization
Corporate
mobiIization
PopuIar
mobiIization
at|ona| po||cy-makers
and dec|s|on-makers
Serv|ce prov|ders
Other government
organ|zat|ons who can
prov|de d|rect or |nd|rect
support
Loca| po||t|ca|, re||g|ous,
soc|a|, and trad|t|ona|
|eaders
Loca| government agenc|es
on-governmenta|
organ|zat|ons
Women's groups
Oo-operat|ves
at|ona| and |nternat|ona|
compan|es
Oommun|ty groups,
househo|ds, am|||es, men,
women, ch||dren
2.8
The 'teacher and pup||'
approach |s very |abour-
|ntens|ve and not a|ways
eect|ve. Hyg|ene promot|on
accentuates pos|t|ve aspects
o 'c|ean' behav|our that
consumers can re|ate to day-
to-day pract|ces.
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How to drive a SanPlat
The promot|on o san|tat|on and the product|on o san|tary wares requ|re tota||y
d|erent sk|||s. Th|s |s recogn|zed |n other markets and shou|d be accepted |n
hyg|ene and san|tat|on promot|on.
The person who bu||ds a car |s d|erent rom the person who se||s that car, who
|s |n turn, d|erent rom the dr|v|ng |nstructor.
SanP|at manuacturers make SanP|ats (page 170). They are not necessar||y the
best peop|e to se|| them, to adv|se customers how to use them, or to suggest
to the|r customers ways o dea||ng w|th ch||dren's stoo|s.
Adults are not clean slates on which to write new ideas.
Adults may have neither the time nor the motivation to learn new
ideas.
New knowledge does not equal new practice.
It is not feasible to expect people to change a whole variety of
hygiene practices.
These are discussed in turn.
Adults are not 'clean slates on which to write new ideas
Classical hygiene education is based on the premise that people
persist in unhygienic practices because they do not know about the
germ theory of disease transmission that microbes cause disease
and so on. Hygiene educators, and others, sometimes equate this with
ignorance and clash with indigenous systems of knowledge.
All societies have concepts of cleanliness which are central to notions
of individual, and group, identity. Throughout the world there are
many explanations for the appearance of diarrhoeal diseases in
children, all of which are internally consistent. In regions as distant
from each other as India, Africa, and Europe diarrhoeal episodes are
attributed to a variety of social, climatic, and environmental factors.
These include the transgression of particular social rules, the
consumption of unsuitable foods, the presence of concurrent illnesses,
teething, and straightforward bad luck (see box opposite).
If we take no account of what adults in the target population know and
we treat them as clean slates on which new (and Western) ideas can
simply be inscribed, then, at best, we create confusion and
incomprehension. At worst the teaching is entirely rejected: these
outsiders have no real idea what is making my child sick.
Solution: Hygiene promotion is founded on knowledge of key aspects
of what people know, do, and want.
Adults may have neither the time nor the motivation to learn new
ideas
Traditional school-type teaching is common in hygiene education
programmes. This may be appropriate for children, but is unlikely to
appeal to adults, especially hard-pressed mothers who have other
higher priorities for their time and energy.
2.8
The evo|ut|on rom hyg|ene
'educat|on' to hyg|ene
'promot|on' has
acknow|edged our key
pr|nc|p|es:
/o0||s a|e |c| c|ea|
s|a|es c| .||c| |c .|||e
|e. |oeas
A|| adu|t soc|et|es have
the|r own |deas o what |s
' c|ean' and o what
causes d|sease. Those
pract|ces and be||es
must be used as the
start|ng po|nt or change,
not |gnored |n the
m|staken be||e that
consumers w||| |nstant|y
re|ect generat|ons o
trad|t|on and rush to
embrace the 'truth' as
pronounced by hyg|ene
educators.
/o0||s ma, |a/e |e|||e|
||e ||me |c| ||e mc||/a||c|
|c |ea|| |e. |oeas
The women o poor
commun|t|es have ||tt|e
t|me to s|t |n on orma|
educat|on sess|ons but
they are the ones most
||ke|y to see the bene|ts
o change and to str|ve to
br|ng |t about. O|ear
messages must be
d|ssem|nated a|ong
eect|ve commun|cat|on
routes.

2
Solution: Hygiene promotion uses repeated, coherent, and simple
messages. These are disseminated through a mix of communication
channels designed to reach target audiences for the greatest effect and
the least cost.
Hew knowledge does not equal new practice
Even if the target audience of the hygiene education programme accepts
the germ theory of disease, this does not guarantee they will change their
hygiene behaviour. Fear is not a good motivation for change. A fear that
germs may make a child ill is unlikely, by itself, to prompt people to
adopt new domestic practices (see first box on page 212).
There are other reasons why new behaviours are not adopted as a
direct result of new learning: the suggested safe practices may be too
expensive or time consuming, appropriate facilities may not be
available, and there may be no support, or even discouragement, from
other members of society. In other words change may be too difficult.
Solution: Hygiene promotion is based on what people can do and
what people want to do. It works to find solutions and not problems.
t is not feasible to expect people to change a whole variety of
hygiene practices
It is likely that only a small number of practices are responsible for
the majority of diarrhoeal episodes (WHO, 1993b). However, hygiene
education programmes rarely identify and target particular risk
practices (see second box on page 212). Getting people to change the
habits of a lifetime is extremely difficult. The more practices that are
targeted the more efforts are diluted.
Folk taxonomies of diarrhoeal diseases in Burkina Faso
Fo|k taxonomy o d|arrhoea| d|seases |n Burk|na Faso the |east |mportant o
wh|ch |s that descr|bed by hea|th educators, o|a|||ee oes o|a|cs or 'wh|te
peop|e's d|arrhoea'
Name
KOLOBO
KOTIGUE
WOLINA
SERE
DIARRHEE DES
BLANCS
Symptoms
Green, rothy, requent stoo|s
\om|t|ng, We|ght |oss
Sma||, muco|d stoo|s,
lrr|tated anus
Fever
Wh|t|sh, ||qu|d stoo|s sme|||ng
o rotten eggs
Sunken ontane||e
Th|ck, wh|t|sh, bad-sme|||ng
stoo|s
Oh||d th|n
L|qu|d stoo|s
Ba||ooned stomach
Causes
Teeth|ng
Oarry|ng the ch||d on the back
Oontact w|th damp ground
Breast-eed|ng mother steps
on an egg
'lnect|on'
Breast eed|ng ater hav|ng
sexua| re|at|ons or wh||e
pregnant
'Paras|tes/worms'
D|rt
2.8
|e. ||c.|eoe oces |c|
eq0a| |e. o|ac||ce
Promot|on must be to
pract|ca| eect,
encourag|ng changes
that are poss|b|e and are
wanted, not mere|y
re|at|ng ||sts o good
hyg|ene pract|ces that,
or the t|me be|ng at
|east, have ||tt|e chance
o be|ng |mp|emented.
|| |s |c| /eas|o|e |c eoec|
oeco|e |c c|a|e a
.|c|e /a||e|, c/ |,|e|e
o|ac||ces
Long 'w|sh ||sts' conuse
consumers and d||ute the
promot|ona| eort.
Attent|on must be
ocused on a ew
pract|ces that present the
greatest r|sk |n the target
commun|ty.
212
2
Ories of resistance from a cholera programme
Government eorts to contro| a cho|era ep|dem|c |n north-eastern Braz|| caused
|nd|gnat|on. Fa/e|a res|dents were h|gh|y res|stant towards the mass med|a
campa|gns and o|c|a| cho|era contro| |ntervent|ons. They were react|ng aga|nst
the accusatory att|tudes and act|ons o the soc|a| e||te.
Oho|era |s popu|ar|y ca||ed 'The Dog's D|sease'. lt carr|es many connotat|ons
and must be understood as part o a h|story o dom|nat|on and soc|a| and
econom|c |nequ|ty |n north-eastern Braz||. The o|c|a| campa|gn, wh|ch used
two stereotypes, oessca |m0|oa (||thy, d|rty person) and /||a |a|a (stray mutt
dog), suered a back|ash as these seemed to equate the poor w|th cho|era
and poverty w|th d|rt. s|ng th|s d|sgrac|ng and d|sempower|ng |magery
b|amed, pun|shed, and st|gmat|zed the poor.
|a||c|s a|o Vc||e, '99
Solution: Hygiene promotion is built by providing simple, attractive
alternatives to a few common risk practices. The process is
systematically planned and monitored and the impact on the targeted
behaviour is measured.
2.8.8 Hygiene promotion in practice
Consumer-oriented, demand-led promotion is an iterative process
with the following stages:
Stage 1 Collaborative data collection
Stage 2 Feedback and discussion with all key stakeholders
Stage 3 Formulation of the hygiene promotion plan
Stage 4 Implementation, monitoring, revision, etc.
If resources and key personnel are available, data collection can be
completed within three months and the feedback and project design
can be completed in a further month. This investment of time and
resources in finding out what people know, do, and want will be
repaid many times over in enhanced programme effectiveness.
wash vegetab|es
||ter dr|nk|ng water w|th sand
p|ace bas|ns o water |n the sun
keep |nger-na||s cut short
wash hands w|th soap
do not wash hands w|th mud
spray |nsect|c|des
wash hands beore eat|ng
wash hands beore eed|ng a ch||d
wash hands ater deecat|on
wash d|rty d|shes ater mea|s
c|ean surrounds
burn rubb|sh
do not bott|e eed
wash |atr|ne s|abs
wash we||
use |y-screens or ood
bo|| dr|nk|ng water
do not sp|t |n pub||c
add d|s|nectants to dr|nk|ng water
ch|or|nate we|| water
bury aeces
construct water conta|ners w|th taps
wash hands beore prepar|ng ood
wash ch||dren's hands
wash hands ater contact w|th ch||d aeces
spr|nk|e ||me
bury rubb|sh
do not store ood
comb ha|r
d|s|nect |atr|ne s|abs
construct |atr|nes
Message overloading in hygiene education
2.8
A three month per|od o
data gather|ng w|th|n the
commun|ty prov|des a
sound base or programme
p|ann|ng and w||| br|ng |ts
own rewards. A short per|od
d|scuss|ng the co||ated
resu|ts w|th the commun|ty
w||| a||ow the ormu|at|on o
a promot|on programme
ounded on what
consumers know, do, and
want. Messages,
commun|cat|on channe|s,
target aud|ences, and
target pract|ces shou|d be
accurate|y de|ned to
ach|eve opt|mum resu|ts.
W
a
t
e
r
A
|
d
/
J
|
m

H
o
|
m
e
s
!
2
The table outlines the key questions and some of the quantitative and
qualitative data-gathering techniques that can be used (Curtis et al.,
1997).
The mix of techniques develops an understanding of the needs, desires,
and perceptions of the target audience, and helps to create like-
mindedness among the project team members and between the project
team and the community.
Different methods will be suitable for answering different questions. For
example, questionnaires are of little use in finding out about peoples
behaviour (Curtis et al., 1993), but may be useful in identifying existing
channels of communication. Setting clear objectives for the data
collection and a commitment to find out what people really know, do, and
think is more important than the choice of methods.
Consultation with key stakeholders is a crucial component of hygiene
promotion. A brief, attractive report presenting the recommendations for
hygiene promotion is widely disseminated. It is translated into local
languages, and made accessible to key stakeholders. A communication
plan listing the key objectives of the programme is then drawn up on the
basis of the findings (see Table 2.8.3).
mplementation of a hygiene promotion programme
The hygiene promotion programme should begin on a small scale.
Time must be allowed for testing and revising strategies in the light of
continued monitoring. Use structured observations to conduct an
initial survey of target behaviour and establish a baseline. Follow this
up at intervals to gauge the extent of behaviour change towards the
Table 2.8.2 Key steps |n a hyg|ene promot|on programme
Objective
Questions to answer Methods
ldent|y r|sk pract|ces
Se|ect pract|ces or |ntervent|on
De|ne target aud|ences
Determ|ne message pos|t|on|ng
Se|ect commun|cat|on channe|s
Wh|ch spec||c pract|ces a||ow
d|arrhoea| m|crobes to be
transm|tted?
Wh|ch r|sk pract|ces are most
w|despread?
Wh|ch r|sk pract|ces are
a|terab|e?
Who emp|oys these pract|ces?
Who |n|uences the peop|e that
emp|oy these pract|ces?
What mot|vates those who
current|y use 'sae' pract|ces?
What are the advantages o the
'sae' pract|ces?
What channe|s are current|y used
or commun|cat|on?
What channe|s are trusted or
such messages?
Ep|dem|o|og|ca| common-
sense
Env|ronmenta| wa|k
Oheck||st observat|on
Structured observat|on
Behav|our tr|a|s
Focus group d|scuss|ons
Structured observat|ons
Focus group d|scuss|ons
Focus group d|scuss|ons
lnterv|ews w|th sae
pract|sers
Behav|our tr|a|s
lnterv|ew representat|ve
samp|e o target
aud|ences
Focus group d|scuss|ons
2.8
Dur|ng |mp|ementat|on the
key requ|rements are to
start on a sma|| sca|e and to
be prepared to mod|y
programme deta||s as the
eects are cont|nuous|y
eva|uated. The eects are
measured |n terms o
behav|oura| change rather
than hea|th bene|ts.
214
2
projects objectives. Monitoring behaviour change is difficult, but
more practical and useful than conducting a health impact study. It is
difficult, and expensive, to separate the signal of the public health
intervention from the noise of parallel events such as epidemics,
economic, climatic, or social change.
2.8.9 Sanitation programmes and the social marketing
approach
Social marketing can be a bridge between technology (hardware) and
behaviour change (software) for effective sanitation programmes. The
following tables take you through the process.
Table 2.8.S Oomponents o a commun|cat|on p|an
Components
ExampIes
Behav|our change ob|ect|ves
Key messages
Target aud|ences
Mot|vat|on or behav|our change
Ohanne|s o commun|cat|on
Oommun|cat|ons mater|a|s
Methods o mon|tor|ng progress
Budget
Pro|ect management
Hand-wash|ng w|th soap ater c|ean|ng a ch||d's
bottom w||| go rom 5% o occas|ons to 35% |n
two years
The targeted hyg|ene pract|ces
Age, sex, number |n each group
Why do the target aud|ences want the new
pract|ces?
Street theatre, house v|s|ts, rad|o, schoo|s
ln programme act|v|t|es
ln programme outputs
ln behav|our change
F|gure 2.8.1. The process o promot|on
2.8
L
S
H
T
M
/
S
a
n
d
y

O
a
|
r
n
c
r
o
s
s
#
2
ExampIes
Notes
Table 2.8.4 A soc|a| market|ng p|an or san|tat|on
Steps
1A Identify data coIIection needs
What are the causes?
What be||es, att|tudes, and current
pract|ces contr|bute to the prob|em
or poss|b|e so|ut|on?
Determ|ne and de|ne the
eva|uat|on |nd|cators (to |nc|ude or
base||ne data)
1B Define the intended audience
Who w||| be most respons|ve to the
|ntervent|on (pr|mary aud|ence)?
Who can support the pr|mary
aud|ence |n |ts new pract|ces?
1C Define feasibIe behaviour(s)
or appropriate products for
each audience
What |s the des|red |dea|
behav|our? Or |dea| product?
What |s the current behav|our? Or
products used?
What are the eas|b|e behav|ours to
be promoted? Or appropr|ate
products?
1D DeveIop the research pIan
What do you need to know?
Who w||| do |t?
What type o research/t|m|ng?
Low |eve| o |atr|ne coverage |n two rura|
prov|nces,
Oh||dren at h|gh r|sk o d|arrhoea| d|sease
Latr|nes are expens|ve
Mater|a|s are hard to |nd
Latr|nes are seen as urban structures
Latr|nes are 'too dangerous' or ch||dren to
use
Pregnant women must not use |atr|nes
Peop|e d|s||ke us|ng the bush at n|ght
F||es and bad sme||s are seen as a
nu|sance
umber o |atr|nes
umber o |atr|nes |n regu|ar use
Proport|on o ch||dren's stoo|s thrown |n
|atr|nes
Fathers take the dec|s|on to buy a |atr|ne
Mothers encourage
Land|ords are constra|ned by |aw to
prov|de |atr|nes (not enorced)
A|||es such as
hea|thworkers
grandmothers
commun|ty |eaders
A |y- and sme||-ree, cheap |atr|ne wh|ch can
be used sae|y by a|| am||y members
Adu|ts go to the bush
Oh||dren deecate |n the yard
Pay|ng a mason to construct a |atr|ne
Buy|ng and us|ng a potty or sma||
ch||dren under three
Why do heads o am||y not buy |atr|nes now?
What wou|d mot|vate them to do so?
Why do mothers not buy pott|es now?
What wou|d mot|vate them to do so?
Pro|ect |e|d team
Pesearch spec|a||st and students
Exper|enced extens|on workers
Soc|o|og|st
Quant|tat|ve |atr|ne coverage survey 400
househo|ds
Focus group d|scuss|ons w|th mothers,
athers, |and|ords
Oonstruct|on o s|x mode| demonstrat|on
|atr|nes
Observat|ons |n 200 househo|ds o ch||d
deecat|on
Tr|a| market|ng o pott|es |n two prov|nces
These cou| d be based on overa| |
programme/pro|ect ob|ect|ves
lnc|ud|ng eva|uat|on |nd|cators w|th data
co||ect|on he|ps measure |mpact at the
end o the programme/pro|ect |nputs
lt a|so means that |normat|on need not
be gathered separate|y and |t thus saves
t|me and resources
ldent|y consumers and the|r tra|ts
De|ne the 'Product' or behav|our
se research or consumer-based data to:
ldent|y 'Pr|ce' and 'P|ace'
2.8
216
2
PossibIe programme goaI or objective Research finding
ExampIes Steps
60% o respondents are aware o
proposed san|tat|on method
On|y 10% o respondents are
aware o d|str|but|on out|et or
san|tat|on product
30% o respondents rate the
san|tat|on product as eect|ve
15% o respondents current|y use
san|tat|on product
15 percentage po|nt |ncrease |n the |eve| o awareness o modern method o san|tat|on
rom 60 to 75% among respondents by two years
A 30 percentage po|nt |ncrease |n awareness o d|str|but|on out|et rom 10 to 40%
among respondents by two years
10 percentage po|nt |ncrease |n eect|veness rat|ng rom 30 to 40% (or mod||cat|on o
the product to ach|eve 40% rat|ng) among respondents by three years
A 5 percentage po|nt |ncrease |n use o san|tat|on product rom 15 to 20% among
respondents by three years
2. EstabIish programme goaIs and objectives
Use res0||s o/ S|ep 1.
ExampIes
Notes Steps
Pesearch resu|ts are very useu| |
the samp|e |s representat|ve o the
tota| popu|at|on to be served
Product Strategy:
What product(s) w||| best u||| the
needs o the |ntended aud|ence/
consumer groups
Price Strategy:
What does |ntended aud|ence
current|y spend |n th|s area?
What can they aord?
Distribution Strategy:
What are the d|str|but|on
channe|s wh|ch are most read||y
access|b|e to the |ntended
groups?
What out|ets do they use?
Where are they most ||ke|y to
|ook or the san|tat|on product?
Advertising and PromotionaI
Strategy
Pesearch |nd|ngs can be used or
Sett|ng the commun|cat|on
ob|ect|ves or the programme or
each |ntended group
The med|a strategy to reach each
|ntended group
5% o househo|ds have a |atr|ne
Overa|| potent|a| market |s 200,000
househo|ds
25% wou|d bu||d a |atr|ne | |t cost |ess
than 50,000F
15% |ntend to bu||d a |atr|ne th|s year
Oonservat|ve est|mate o potent|a| market
|s 20,000 |atr|nes |n two years
A cho|ce o mode|s at d|erent pr|ces
Ourrent mode|s are \lPs constructed by a
prev|ous pro|ect. They were prov|ded ree.
\lPs are too expens|ve or most
househo|ds.
Mason's shops |n |oca| market towns
\|||age mason
Masons promote |atr|nes on market days
Extens|on worker makes house-to-house
v|s|ts w|th brochures/|nv|tat|ons to v|s|t
demonstrat|on |atr|nes
The data can be pro|ected or the who|e
popu|at|on and the s|ze o the market (and
potent|a| demand) can be ca|cu|ated
sage data w||| prov|de est|mates o
the overa|| s|ze o the current market
'lntent|on to use' can pred|ct the
potent|a| market
Oost ca|cu|at|ons shou|d |nc|ude both
o||ec| eoe|o||0|es o money and
resources and
|nd|rect costs e.g.
t|me
energy
embarrassment (d||cu|t to quant|y)
3. Estimate the potentiaI market for a given brand or product
4. DeveIop a marketing 'mix' strategy
Lse ||e ||/c|ma||c| /|cm S|eo ' /c| oe/e|co|| ma||e||| m|
2.8
%
2
ExampIes
Notes Steps
w|e| oe/e|co|| ||e ma||e||| s||a|e, ,c0 |eeo |c ||c. ...
Current usage
What methods and products are
consumers us|ng, | any?
What |s the compet|t|on?
Attitudes/perceptions
What bene|ts are re|evant,
mean|ngu|, and persuas|ve?
What barr|ers w||| need to be
overcome?
Product image
What |s the |mage o e|ther the
method or product or brand
among the |ntended aud|ence?
How can th|s be |mproved?
Consumer communication
What |normat|on does the
|ntended aud|ence want and
need to use?
What sources does the |ntended
aud|ence current|y use or
|normat|on?
Wh|ch one(s) do they be||eve?
What other potent|a| med|a are
ava||ab|e?
Some \lPs
Land|ords have prov|ded s|mp|e |atr|nes |n
some compounds
Advantages |nc|ude
pr|vacy, d|gn|ty, and conven|ence
Ma|n barr|ers
Oost
Prev|ous |atr|nes were subs|d|zed
\lPs seen as very grand, on|y or the
wea|thy
\lPs seen as to be kept or adu|ts and
v|s|tors on|y
Emphas|ze |ow-cost mode|s
Stress ch||d use
M|spercept|ons about cost and danger
to ch||dren need correct|ng
61% o ma|e heads o househo|d ||sten to
|oca| rad|o regu|ar|y
72% o women attend week|y market
Bapt|sms and wedd|ngs
Oons|der sources o |normat|on or
product eect|veness
product ava||ab|||ty
correct|ng any m|spercept|ons
2.8
218
2
Further reading
Almedom, A., Blumenthal, U., and Manderson, L. (1997) Hygiene
Evaluation Procedures: Approaches and methods for assessing water-
and sanitation-related hygiene practices, International Nutrition
Foundation for Developing Countries.
This book provides the non-expert with guidelines for evaluating
water- and sanitation-related hygiene practices. It focuses on the
practical concerns of field personnel and enables existing field staff to
carry out hygiene behaviour diagnoses. The book looks at how to
gather, review, and interpret qualitative information. It weighs the
pros and cons of a wide range of techniques and assumes no prior
knowledge of social sciences.
Ankur Yuva Chetna Shivir (1996) Diarrhoea and hygiene in Lucknow
slums. A document produced for the Gomti River Pollution Control
Project, Lucknow, London School of Hygiene and Tropical Medicine,
June.
An account of a hygiene promotion project in Lucknow which was
written for, and disseminated to, project stakeholders. Producing an
accessible report is integral to the process of increasing the
ownership of the project. This is attractive and easy to read and
shows how the project was designed and what lessons were learned.
Boot, M.T. (1991) Just Stir Gently: The way to mix hygiene education
with water and sanitation, IRC Technical Paper No.29, IRC
International Water and Sanitation Centre, The Hague.
As the title suggests the main concern of this book is hygiene
education, and it is based on the paradigm most prevalent in the USA.
The book considers issues in project design: for example, negotiations
with project stakeholders needed to introduce behavioural
components, and the timing of articulating behavioural components
with other project components. This is still a good source of
techniques for data collection and it stresses the importance of both
finding out, and working with, what people know.
Boot, M.T. and Cairncross, S. (1993) Actions Speak: The study of
hygiene behaviour in water and sanitation projects, IRC International
Water and Sanitation Centre, The Hague and London School of
Hygiene and Tropical Medicine, University of London.
A comprehensive analysis of ways of studying hygiene behaviour and
interpreting the results. The recommended approaches are
demonstrated with lots of practical examples and anecdotes. Planning
and pre-testing hygiene behaviour studies, involving community
members in study design and information gathering methods, the
types of behaviours most relevant to achieving health improvements,
and different interviewing techniques are all considered.
2.8
'
2
Cairncross, S. (1992) Sanitation and Water Supply: Practical lessons
from the Decade, UNDP-World Bank Water and Sanitation Discussion
Paper No.9, UNDP-World Bank, Washington DC.
A personal perspective on the ten-year effort to provide low-cost
waste facilities. This is a concise explanation of how water-supply and
sanitation programmes are part of a wider picture which includes land
tenure, housing, drainage, and solid-waste disposal, etc. The main
lesson is that sustainable success depends on consumer demand and
that programmes should be designed and managed to sell a product,
e.g. water supply and sanitation, and not to provide a service.
Curtis, V. (1997) Hygienic, happy and healthy. A series of practical
manuals designed to help you set up a hygiene promotion programme.
Part 1. Planning a hygiene promotion programme. Draft manual
prepared for UNICEF.
This series of manuals describes how to carry out the data collection
vital for the design of an intervention. They are very readable and
have lots of graphics.
Curtis, V., Sinha, P. and Singh, S. (1997) Accentuate the positive:
Promoting behaviour change in Lucknows slums Waterlines, Vol.16
No.2. pp.5-7.
A brief article by the project team in Lucknow. It covers the
techniques used when planning a hygiene promotion intervention and
reminds readers of the need for good news, not doom and gloom.
WASH (1993) Lessons Learned in Water, Sanitation and Health:
Thirteen years of experience in developing countries, Water and
Sanitation for Health Project, USAID, Washington DC.
A review of the lessons WASH took from the Water Decade. The
book looks at technical assistance, at shared responsibility and
different stakeholders in partnerships, at all levels of programme
strategies, and at long-term sustainability and the importance of
enabling behaviour change through a range of initiatives.
2.8