Newsletter 1, October 2001

Year of publication: 2003

This is the first newsletter informing you about a multi-country research project investigating the sustainability of changes in hygiene behaviour. We will begin by telling you a bit more about the background of the research and how it is set up. Then you can read contributions from the research teams from NETWAS-Kenya (Beth Karanja and Vincent Njuguna), NEWAH-Nepal (Renuka Rai and Saraswati Khanal), WaterAid-Uganda (Joyce Mpalanyi Magala and Brenda Nahidu), VRCWS-Ghana (Emmanuel Nyavor), COSI-Sri Lanka (Palitha Jayaweera and Chandrika Jayasekara) and SEUF-India (Dr. Panicker and Suma Zacharia). Should you want to react or request further information about the project, please get in touch with one of us. You will find the contact details here.

About the research and the research partners

It has been almost a year since the start of this project, which aims to study the sustainability of changes in hygiene behaviour. The project combines a so-called concerted action financed by the European Commission (EC) and actual field research, financed by the Dutch government (DGIS) and the project partners. This project will last three years and has the following objectives:

• To develop an active network in the field of hygiene promotion;
• To assess the level of sustainability of behavioural change one to three years after a hygiene promotion intervention;
• To develop a methodology for simple/cost-effective longitudinal monitoring of behavioural changes;
• To gain insight into relationships between project approaches, external conditions and sustainability of changes in hygiene behaviour;
• To determine policy and programming implications and influence policy to increase the effectiveness of water and sanitation programmes.

IRC International Water and Sanitation Centre, the research coordinator, is the contractual partner of both the EC and DGIS. A total of eight partners have been sub-contracted by IRC. These are:

• Network for Water and Sanitation, Kenya ( NETWAS);
• WaterAid Uganda ( WAU), which works in collaboration with Uganda Association for Socio-Economic Progress (USEP)
• Volta Region Community Water Supply and Sanitation Agency, Ghana ( VRCWSA);
• Nepal Water for Health Organisation ( NEWAH);
• COSI-Foundation for Technical Cooperation, Sri Lanka ( COSI);
• Socio-Economic Units Foundation, Kerala, India ( SEUF);
• London School of Hygiene and Tropical Medicine, United Kingdom ( LSHTM);
• German Agency for Technical Cooperation, Germany ( GTZ).

Developing the research

After settlement of the contractual issues a two-week international workshop was organized from February 5-16, 2001. The Asian and African research partners all delegated two staff -members, the European partners only one. The workshop objectives were to:

• outline the current state of knowledge and experiences with regards to the relationship between hygiene promotion approaches applied and the sustainability of changes in hygiene behaviour;
• consolidate the network of research partners;
• identify knowledge gaps;
• develop an approach for field research to build on the current knowledge level with particular attention to sustainability;
• identify activities for active dissemination of the current knowledge and the research results.

With respect to the current state of knowledge and experiences it was concluded that over recent years there has been intensive investigation to learn more about the specific hygiene practices that need to be promoted because they give the greatest health advantage. These are: i) safe handling of water, ii) latrine construction and use, and iii) washing hands after visiting the latrine and before handling food. We have also learned that in reality knowledge and practice often do not go hand in hand: the knowledge of safe practices may be high, but may not necessarily result in exercising safe practices.

Less is known, however, about precisely how hygiene practices can best be promoted in different settings, so that these practices and their health impact may be sustained. It is assumed that active involvement and discussion about the behaviours and interventions are important factors for sustained improvement in behaviours. There are a large number of such assumptions and gut feelings currently determining hygiene promotion approaches. But indeed, little is certain. The theoretical and experiential basis for detailed planning of promotional activities needs further emphasis.

During the workshop it also became evident that many of the health impacts or behavioural studies that do exist appear to be insufficiently scientific. They do not meet the criteria for scientific rigour as developed by Loevinsohn (1990), who states that studies need to:

• provide a description of the intervention, sufficiently detailed to allow for replication;
• provide a description of the target audience to allow for comparison with other settings;
• use a control group and a sample of more that 60 individuals or 2 villages;
• have an objective outcome, describing change in either behaviour or health status.

Within a commonly defined research framework, the study teams from the partner oganizations developed their own research hypotheses, research plan and tools for data collection. Most of them centred around hand washing, use and maintenance of a latrine, and water storage. The workshop was to result in a meaningful and feasible overall research plan and meaningful and feasible country-specific research plans and appropriate tools. To best achieve this goal, a workshop approach was adopted whereby the selection of behaviours to be studied was connected to the hygiene implementation activities of the Asian and African members. In addition there was a consensus that the hypotheses to be tested were to be country specific and applicable to the programmatic and environmental situation of the research teams. All research teams adopted data collection methods that provide reliable, valid and useful information as well as sample sizes that are on the one hand big enough to show significance and on the other hand manageable with the resources available. Sample communities were chosen from communities where hygiene promotion interventions ended in 1998 or 2000.

It needs to be stressed that the research is not meant to compare the hygiene promotion performance of the organizsations involved, but to determine the validity of certain hypotheses about what makes changes in hygiene behaviour sustainable.

Some examples of hypotheses identified

• If the socio-economic status of families is high, then hand washing tends to be sustained.
• If hand washing facilities and soap are readily available, then students tend to continue hand washing.
• If the water point is close to the household, then proper maintenance of the latrine tends to be continued.

Getting prepared for the research

Back in their offices the teams set out to implement the research, starting with an informative session with their own colleagues to create an organization-wide interest in the research. Tools developed during the workshop required careful testing before they could be applied on a wider scale. The teams combined testing of the tools with the training of enumerators. This allowed them to get feedback from the end users of the tools and to see the enumerators perform in the field. After having been tested, the research plans and the tools were adapted and finalized.

Even if the teams had access to experienced enumerators, training was required because it is crucial that all enumerators use similar criteria when judging the quality of a latrine or the quality of hand washing. The criteria also need to be in line with what was promoted through the hygiene education intervention.

The training events were also used to discuss the roles and responsibilities of all involved.

The first survey

In the period, from July - October, all members carried out the first survey. In all countries 100-150 households were visited for observation, demonstration and questioning. In some cases schools were also visited and focus group discussions held. Data was entered in Excel sheets and at this point in time the Epi-info data analysis programme was used to analyze the data and to produce two-by-two matrices that visualize the hypotheses and that show the relationship between factors, such as the availability of water, and the behaviour, such as hand washing.

Below you will find some experiences from the research partners. Should you have questions or suggestions, please do not hesitate to contact any of us. You will find the contact details here.