Improving Hygiene at Scale

Overview

• Definition

• Principles

• Process

• Results

• Timeframe

• Characteristics

• Phases

What is Scale?

Coordinated actions of all stakeholders working toward a common goal to

significantly reduce disease rates in large numbers of affected people

Scale Principles

• Participatory• Process-oriented • Negotiation• Informed decision-making• Acknowledging & valuing

Moving forward together in partnership

Process

Reduce Diarrheal Disease

1. MAP

3. STRATEGIZE5. MONITOR

6. VALUE

4. ACT

2. PARTNER

1. Map the context & detail the stakeholders in all sectors, the levels at which they work, the networks & relationships that already exist & examine patterns of individual &

institutional behaviors.

2. Leverage partnerships, strengthen

existing networks & relationships, & create

new, non-traditional ones.

3. Develop a common goal &

delineate a behavior change

strategy.

4. Implement activities & interventions detailed in the

strategy around the common goal in a concerted & overlapping way.

5. Track the progress of

interventions to make adjustments,

adaptations & changes as

needed.

6. Assess the outcomes & impact of the scale effort.

Expected Results

• Increased percentage of targeted audience adopting and sustaining key improved practices

• Reduced number of diarrheal diseases cases

• Reduced percentage of children under 5 dying of diarrheal disease

Timeframe

• Map, Partner, Strategize – 8 to 15 months

• Act – 1 to 3 years

• Monitor – during action

• Value – at least yearly during action

TOTAL Length Required – 3 to 5 years

Characteristics of a Scale Effort

Systems-Approach Behavior FIRST Multiples Institutionalization Hygiene Improvement Framework. Coverage

Systems-Approach

Emphasize:• relationships and

patterns of behavior• that a small event in 1

sector can have a tremendous impact elsewhere

• key influence points

Examine: • the WHOLE• relationships• degrees of freedom• mainstreaming• patterns• commonalities• opportunities

Behavior First

• Focus on improving key individual hygiene practices

• Identify, promote and facilitate improved practices

• Design interventions that motivate and facilitate these improved practices

Practices that people are willing and able to

practice

Multiples

• Multiple interventions

• Multiple levels

• Multiple stakeholders

• Multiple options

Institutionalization

Any organized stakeholder group

• Institutional policy adjustments • Human resources, budget and integration

commitments • Continued support for activities “political will”• Heart of sustainability • Institutional behavior change desired

“Making something a new routine”

Hygiene Improvement Framework (HIF)

• Communication• Social mobilization• Community participation• Social marketing• Training

HygienePromotion• Water Supply

• Sanitation systems• Available Household

Technologies and Materials

Access to Hardware

• Policy improvement• Institutional strengthening• Financing and cost-recovery• Cross-sectoral coordination• Partnerships

Enabling Environment

Hygiene Improvement

Diarrheal Disease Prevention

Coverage

QUANTITY

Ensure Large-Scale through:

• Health impact realized• Total population

covered and/or• Geographic area(s)

covered

QUALITY

Ensure Sustainability by:• Intervention

concentration• Activity saturation• Systems interaction• Institutionalization• Critical mass

behavioral impact

Well Construction

Handwashing Promotion

Latrine Construction

Hygiene Advocacy

Traditional Coverage

Focus on Geographic and Population Coverage

Scattered, dispersed, stand-alone

Scale CoverageConcentrate, saturate,

interact

Using a systems-approach, focus on Geographic Area, Population, AND Multiples.

Wells Handwashing Latrines Advocacy

Appropriate Approaches to Promotion

Needed Infrastructure, Products, & Services

Supportive Environment

Ensuring all the necessary elements, increases

likelihood of behavior

change and the sustainability of

the practice.

Maximum potential for

change exists here.

Increase the Likelihood of Improved Practice Adoption

& Sustainability

Map, Partner, Strategize

Preparation Phase:• Mapping• Partnering• Intervention zone(s) determination• ‘Whole system in a room’ process• Formative research (as needed)• Behavior change (BC) strategy development• Effort index design• Resource identification

Solid Preparation is ESSENTIAL!

• Understand the context through mapping

• Clarify present partner roles

• Agree on geographic coverage

• Understand behavior change approaches used

Mapping

• WHAT – Understand the setting in which the effort will take

place

• WHY– Take a systems-wide look to effectively assess

options and implications of decisions

• HOW – Mapping:– Geographic– Dimensional– Associative

Issues to Map

• Water sources, access, quality & supply

• Sanitation access, quality & supply

• Partner areas of intervention & activities

• Partner relationships• Geographic location of

institutional staff and kinds of interventions

• Geographic areas of greatest need including health and non-health platforms

• Existing infrastructures, e.g. clinics, churches,

• SES indicators, e.g. income, gender, etc.

• Capabilities of ancillary agencies, e.g. universities, colleges, market places, roads, railroads, schools

• Market paths & streams per needed product

• Communication channels

• Donor program support

DRC – Before: Stakeholder Relationships

SANRU

MOHMOW

Health Ctrs

DistHealth

Village Chiefs

USAID

Mobilizers

DistWS

Water Cmt

Village Cmt

DRC – After

MOWMOH USAID

SANRU

Water Cmte

Health Ctrs

Mobilizers

DistWS

EZdS Village Chiefs

MOE

3 NGOs

2 CSOs

DANIDAWB

DistEd

DistHeatlh

MOEnv

DistEnvVillage Cmt

Partnering Who & How

WHO:

• Start with stakeholders directly related to issue• Expand to:

– other channels of influence – groups with potential long-term impact– all possible information channels

HOW:

• Make individual relationships within these groups, not just institutional relationships.

• Treat each group with respect.

Partnering Systems Examination

Examine the systems and ask:

“What needs to be done to turn you into a partner with an active or passive influence

on the targeted audience?”

Training? Institutional strengthening?Capacity building?Expansion of reach?Other?

Intervention Zone Determination

• Consider systems-approach & Scale multiples• Examine appropriate, relevant statistics:

– Number of children under 5– Diarrhea disease prevalence in under 5s– Access to water– Access to sanitation

• Detail geographically where partners are working

• Examine types of interventions by partner• Choose together

Whole System in a Room Process

• Focus on the past

• Focus on the present

• Focus on the future

• Formulate common ground

• Make broad commitments

• Formulate action plans

Media

CSOs

Educational Institutions

Commercial Businesses

MothersGovernment

Ministries

Donors/Funders

Religious Groups

NGOs

Develop Orgs

R&D Institutions

Using Hygiene

Improvement to reduce diarrheal diseases

Whole System for HI could include:

Research & Experience

• Form basis for key behaviors

• Allow for community involvement

Behavior Analysis & Intervention Design

• Analyze behaviors & identify feasible with specific audience

• Develop broad activities for overarching intervention areas

• Make/Get specific commitments for interventions & activities

• Encourage continued community involvement

BCS Development Process

Strategy Design

Behavior Change Strategy

A. Behavior Analysis : actual desired feasible

B. Delineation of Overarching Intervention Areas :1. Communication2. Training3. Infrastructure/Service Improvements4. Products/Equipment5. Policy/Advocacy6. Mobilization7. Financing

Based on motivators & barriers

Behavior Analysis

Desired Actual Motivators Barriers Feasible

Diarrheal Diseases Wash hands with soap & water and towel dry at 5 critical times.

Wash hands occasionally without soap/ ashes, with used, dirty water and dry on dirty clothing.

•Access to safe water source

•Access to soap

•Clear understanding of importance

•Knowledge of steps required

•Support from immediate community

•No access to safe water sources

•Limited access to products needed

•Feel unimportant or unnecessary

•No community agents to help with questions or concerns

Wash your hands with soap & clean water and air dry before eating.

Audience: Mothers aged 18 to 30

Communication Activities

Training Activities

Infrastructure Activities

Product Activities

Policy Activities

Mobilization Activities

Financing Schemes

Encourage mothers aged 18-30 to wash hands before eating with soap & clean water & air dry.

Demos

Flipcharts

Experience of “healthy families”

Manuals

Complete education kit

Educational games

Theatre, songs

Train agents:

Proper hand washing

Basic water issues

How to conduct community meeting

Train community members:

Pump repair

Soap making

Provision of adequate safe water sources

Soap

Basins

Soap making kits

Wagons

Advocacy on hand washing

Inclusion of govt. in activities

Contest for “clean family”

Support associations

Creation of water committees

Community participation in decision making

Delineation of Interventions

Voucher system

WATSAN collection

Act

Implementation Phase:• Systematic roll-out of

hardware, promotion, and enabling environment interventions

• Assistance in implementing “mix” of behavior change approaches

• Technical assistance

Plan Development

• Prepare implementation plans for interventions and intervention activities

• Develop clear management and roll out plan

• Implement

• Keep the community involved

Implementation

Management Plan

Roll Out Plan

• Timing is essential

• Activities are interdependent

• Activities and actions build on other activities and actions

Monitor

Monitoring Phase:

•Roll out on schedule

•Coverage and overlaps happening

•“Must do’s” occurring

Value

Evaluation Phase:•Sustainability•Integration•Partnerships•Improved practices•Desired impact

WHAT• Indices to describe the types of program efforts and

monitor them over time. • A composite index designed to:

– measure commitment and program effort– capture inputs and outputs

• A score made up of 3 main components (HIF) of an effective response:– access to hardware– enabling environment– hygiene promotion

WHY• Standard measures needed to quantify the nature

strength of efforts/activities.

Hygiene Effort Index

HIF Component

Sub-component

When Did Benefit Occur

Beneficiary Level

Attributes to Assess

Access to Hardware

Sanitation

New Access

HouseholdIncrease the percentage of households with new access to improved sanitation facility

CommunityIncrease the percentage of communities with new access to improved sanitation facilities

SchoolIncrease the percentage of public and private schools with newly established handwashing stations near toilets/latrines in rural and peri-urban areas

Renovated Access

HouseholdIncrease the percentage of household with renovated access to (improved) sanitation systems

CommunityIncrease the number of communities with improved access to sanitation systems

SchoolIncrease the percentage of public and private schools with renovated handwashing stations near toilets/latrines in rural and periurban areas

How